lobal Initiative for Chronic bstructive ung isease

1. lobal Initiative for Chronicbstructiveungisease GOLD

2. GOLD Website Address http://www.goldcopd.com Dr. David P. Breen

3. Facts About COPD • COPD is the 4th leading cause of death in the United States (behind heart disease, cancer, and cerebrovascular disease). • In 2000, the WHO estimated 2.74 million deaths worldwide from COPD. • In 1990, COPD was ranked 12th as a burden of disease; by 2020 it is projected to rank 5th. Dr. David P. Breen

4. 1. 2. Cancer 538,947 3. Cerebrovascular disease (stroke) 158,060 4. Respiratory Diseases (COPD) 114,381 5. Accidents 94,828 Pneumonia and influenza 93,207 6. Diabetes 64,574 7. Suicide 29,264 8. Nephritis 26,295 9. 10. Chronic liver disease 24,936 All other causes of death 469,314 Leading Causes of DeathsU.S. 1998 Cause of Death Number Heart Disease 724,269 Dr. David P. Breen

5. Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 Proportion of 1965 Rate 3.0 Coronary Heart Disease Stroke Other CVD COPD All Other Causes 2.5 2.0 1.5 1.0 0.5 –59% –64% –35% +163% –7% 0 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 Dr. David P. Breen

6. Age-Adjusted Death Rates for COPD, U.S., 1960-1998 Deaths per 100,000 60 50 40 30 20 10 0 Dr. David P. Breen 1960 1965 1970 1975 1980 1985 1990 1995 2000

7. Facts About COPD: U.S. • Between 1985 and 1995, the number of physician visits for COPD increased from 9.3 to16 million. • The number of hospitalizations for COPD in 2000 was estimated to be 726,000. • Medical expenditures in 2002 were estimated to be $18.0 billion. Dr. David P. Breen

8. Facts About COPD • Cigarette smoking is the primary cause of COPD. • In the US 47.2 million people (28% of men and 23% of women) smoke. • The WHO estimates 1.1 billion smokers worldwide, increasing to 1.6 billion by 2025. In low- and middle-income countries, rates are increasing at an alarming rate. Dr. David P. Breen

9. Irish Figures • Diseases of the Respiratory system are the cause of one in five deaths in Ireland today • In 1999 , Respiratory disease caused 7100 deaths: 3700 in men and 3400 in women • 26% of respiratory deaths were due to COPD =1846 COPD-related deaths • Clear social gradient: Respiratory mortality in the lowest occupational class was 200% higher than the highest occupational class Inhale survey Dr. David P. Breen

10. Clinically apparent disease Subclinical/ undiagnosed disease Dr. David P. Breen

11. COPD and Smoking • 95% of COPD is caused by smoking • 45% of young Irish adults are current smokers • Prevalence of current smokers is higher in females (46.5% female v 44.2% male) • 30% of school-leavers smoke ECRHS Group Dr. David P. Breen

12. Smoking in Ireland Adults • 43% in 1973  29% in 1994  27% now • highest in lowest SE groups • declining more slowly in women than men Children and teenagers • 1/10 6th class pupils smoke regularly, 15% boys, 5% girls • 1/2 6th class pupils have tried smoking • smoking increases steadily in teens in both sexes • 30-35% of 17 yo Dublin schoolchildren smoke regularly, equal in both sexes Dr. David P. Breen

13. Lung Function decline Dr. David P. Breen

14. Dr. David P. Breen

15. lobal Initiative for Chronicbstructiveungisease GOLD

16. GOLD Workshop Report: Contents • Introduction • Definition and classification • Burden of COPD • Risk factors • Pathogenesis, pathology, and pathophysiology • Management • Future research

17. Definition of COPD Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. Dr. David P. Breen

18. Burden of COPD Key Points • The burden of COPD is underestimated because it is not usually recognized and diagnosed until it is clinically apparent and moderately advanced. • Prevalence, morbidity, and mortality vary appreciably across countries but in all countries where data are available, COPD is a significant health problem in both men and women.

19. Burden of COPD Key Points • The global burden of COPD will increase enormously over the foreseeable future as the toll from tobacco use in developing countries becomes apparent.

20. Burden of COPD Key Points • The economic costs of COPD are high and will continue to rise in direct relation to the ever-aging population, the increasing prevalence of the disease, and the cost of new and existing medical and public health interventions.

21. Direct and Indirect Costs of COPD, 2002 (US $ Billions) • Direct Medical Cost: $18.0 • Total Indirect Cost: $ 14.1 • Mortality related IDC 7.3 • Morbidity related IDC 6.8 • Total Cost $32.1 Source: NHLBI, NIH, DHHS Dr. David P. Breen

22. Risk Factors for COPD Host FactorsGenes (e.g. alpha1-antitrypsin deficiency) Hyperresponsiveness Lung growth ExposureTobacco smoke Occupational dusts and chemicals Infections Socioeconomic status Dr. David P. Breen

23. Pathogenesis of COPD NOXIOUS AGENT(tobacco smoke, pollutants, occupational agent) COPD Genetic factors Respiratory infection Other Dr. David P. Breen

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27. Causes of Airflow Limitation • Irreversible • Fibrosis and narrowing of the airways • Loss of elastic recoil due to alveolar destruction • Destruction of alveolar support that maintains patency of small airways Dr. David P. Breen

28. Causes of Airflow Limitation • Reversible • Accumulation of inflammatory cells, mucus, and plasma exudate in bronchi • Smooth muscle contraction in peripheral and central airways • Dynamic hyperinflation during exercise Dr. David P. Breen

29. Objectives of COPD Management • Prevent disease progression • Relieve symptoms • Improve exercise tolerance • Improve health status • Prevent and treat exacerbations • Prevent and treat complications • Reduce mortality • Minimize side effects from treatment Dr. David P. Breen

30. GOLD Workshop ReportFour Components of COPD Management • Assess and monitor disease • Reduce risk factors • Manage stable COPD • Education • Pharmacologic • Non-pharmacologic • Manage exacerbations Dr. David P. Breen

31. Assess and Monitor Disease: Key Points • Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms. Dr. David P. Breen

32. Assess and Monitor Disease: Key Points • Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnea. Dr. David P. Breen

33. Assess and Monitor Disease: Key Points • For the diagnosis and assessment of COPD, spirometry is the gold standard. • Health care workers involved in the diagnosis and management of COPD patients should have access to spirometry. Dr. David P. Breen

34. Assess and Monitor Disease: Key Points • Measurement of arterial blood gas tension should be considered in all patients with FEV1 < 40% predicted or clinical signs suggestive of respiratory failure or right heart failure. Dr. David P. Breen

35. Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation dyspnea indoor/outdoor pollution è SPIROMETRY Dr. David P. Breen

36. Spirometry: Normal and COPD Dr. David P. Breen

37. Factors Determining Severity Of Chronic COPD • Severity of symptoms • Severity of airflow limitation • Frequency and severity of exacerbations • Presence of complications of COPD • Presence of respiratory insufficiency • Comorbidity • General health status • Number of medications needed to manage the disease Dr. David P. Breen

38. Classification by Severity Stage Characteristics 0: At riskNormal spirometry Chronic symptoms (cough, sputum)  I: MildFEV1/FVC < 70%; FEV1 ³ 80% predicted With or without chronic symptoms (cough, sputum) II: ModerateFEV1/FVC < 70%; 50% £ FEV1 < 80% predicted With or without chronic symptoms (cough, sputum, dyspnea) III: Severe FEV1/FVC < 70%; 30% £ FEV1 < 50% predicted With or without chronic symptoms (cough, sputum, dyspnea) IV: Very Severe FEV1/FVC < 70%; FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure Dr. David P. Breen

39. GOLD Workshop ReportFour Components of COPD Management • Assess and monitor disease • Reduce risk factors • Manage stable COPD • Education • Pharmacologic • Non-pharmacologic • Manage exacerbations Dr. David P. Breen

40. Reduce Risk FactorsKey Points • Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD. • Smoking cessation is the single most effective - and cost effective - intervention to reduce the risk of developing COPD and stop its progression (Evidence A).

41. Reduce Risk FactorsKey Points • Brief tobacco dependence treatment is effective (Evidence A), and every tobacco user should be offered at least this treatment at every visit to a health care provider. • Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment (Evidence A).

42. Reduce Risk FactorsKey Points • Several effective pharmacotherapies for tobacco dependence are available (Evidence A), and at least one of these medications should be added to counseling if necessary, and in the absence of contraindications.

43. Reduce Risk FactorsKey Points • Progression of many occupationally-induced respiratory disorders can be reduced or controlled through a variety of strategies aimed at reducing the burden of inhaled particles and gases (Evidence B).

44. Brief Strategies To Help The Patient Willing To Quit Smoking • ASKSystematically identify all tobacco users at every visit. • ADVISEStrongly urge all tobacco users to quit. • ASSESSDetermine willingness to make a quit attempt. • ASSIST Aid the patient in quitting. • ARRANGESchedule follow-up contact.

45. GOLD Workshop ReportFour Components of COPD Management • Assess and monitor disease • Reduce risk factors • Manage stable COPD • Education • Pharmacologic • Non-pharmacologic • Manage exacerbations Dr. David P. Breen

46. Manage Stable COPD Key Points • The overall approach to managing stable COPD should be characterized by a stepwise increase in the treatment, depending on the severity of the disease. • For patients with COPD, health education can play a role in improving skills, ability to cope with illness, and health status. It is effective in accomplishing certain goals, including smoking cessation (Evidence A). Dr. David P. Breen

47. Manage Stable COPD Key Points • None of the existing medications for COPD has been shown to modify the long-term decline in lung function that is the hallmark of this disease (Evidence A). Therefore, pharmacotherapy for COPD is used to decrease symptoms and/or complications. Dr. David P. Breen

48. Manage Stable COPD Key Points • Bronchodilator medications are central to the symptomatic management of COPD (Evidence A). They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms. • The principal bronchodilator treatments are beta2-agonists, anticholinergics, theophylline, and a combination of these drugs (Evidence A). Dr. David P. Breen

49. Bronchodilators in Stable COPD • Bronchodilator medications are central to symptom management in COPD. • Inhaled therapy is preferred. • The choice between beta2-agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects. Dr. David P. Breen

50. Bronchodilators in Stable COPD • Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms. • Regular treatment with long-acting inhaled bronchodilators is more effective and convenient than treatment with short-acting bronchodilators, but more expensive. • Combining bronchodilators may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator. Dr. David P. Breen