2Objectives Defining COPD To be familiar with the new GOLD classification system
3COPD Defined by GOLDCOPD as a disease state is characterized by airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.GOLD=Global Initiative for Chronic Obstructive Lung DiseaseWhat is airflow limitation? Post bronchodilator FEV1/FVC ratio less than 0.70
4OLD Subtypes Chronic bronchitis: Emphysema: chronic productive cough for 3 months in 2 consecutive years.Emphysema:Abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of airspace walls without obvious fibrosis.Chronic obstructive asthma:Asthma with airflow obstruction that does not remit completelyREFERENCE SLIDE to show that current definition of COPD no longer separates these subtypes due to the spectrum of manifestations and related processesIf asked why exclusion of fibrosis for emphysema? Intended to distinguish emphysema from interstitial pneumonias. However, many studies indicate that fibrosis can be a component of emphysema and less commonly, emphysema can exist in individuals who do not have airflow obstruction If asked for definition of Asthma: (National Asthma Education and Prevention Program Expert Panel) -a chronic inflammatory disorder of the airways. The chronic inflammation is associated with airway responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variably, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.
5revised GOLD classification Looks at 3 things:SymptomsFEV1History of exacerbationsWhy the new system? A good question for the listeners is, what if two patients are in the same class but different exercise tolerance or functional capacity? They should not be treated the same, therefore, the revised GOLD classification uses symptoms, FEV1, history of exacerbations to assess the exacerbation risk and guide therapy
6Grading symptomsThis is how symptoms are graded in the new system. Can either use this-MMRC or CAT scale
7Grading severity of airflow In patients with FEV1/FVC <0.70GOLD 1MildFEV1>80%GOLD 2Moderate50%<FEV1<80%GOLD 3Severe30%<FEV1<50%GOLD 4Very severeFEV1<30%Point out that FEV1/FVC ratio used to be the only factor in the old classification system. In a sense, we are using the same 1-4 ratios of FEV1 as the old system here, but it is now one of three factors in the new classification system
8historyPutting it all together for the new classification system. Going from top to bottom, symptoms, airflow limitation, and exacerbations-which is based on low risk=less than or equal to 1 per year or high risk=greater than or equal to 2 per year.Then going down to bottom half of table 4, notice that A and B are low risk -> C and D highest risk. Pick the highest risk column that spirometry or exacerbation history fits into.
9CASE74 YO M with COPD p/w SOB x 2 days. At baseline he does not have any physical limitations. His last spirometry three years ago showed mild COPD. He was never given any inhalers besides a rescue inhaler that he seldom uses. He has never been intubated, but gets about 3 exacerbations per year. 2 days ago he required it around the clock after having URI symptoms. He has increased greenish sputum over the past couple of days. He called 911 after waking up SOB. He was given duonebs and placed on CPAP.What classification is he?Grade 0 symptoms, Grade 1 spirometry, >2 exacerbations. So class C
10summaryCOPD is characterized by airflow limitation, progressive, and has an enhanced chronic inflammatory response.Revised GOLD classification uses FEV1, symptoms, history of exacerbationsIt’s still important to know the OLD FEV1 classification system because it’s used in the NEW GOLD classification.For diagnosis and exacerbation treatment of COPD, see the newly revised COPD mini lecture!
11ReferencesGlobal Strategy for the Diagnosis, Management, and Prevention of COPD Updated 2013 Uptodate