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G O L D lobal Initiative for Chronic bstructive ung isease.

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Presentation on theme: "G O L D lobal Initiative for Chronic bstructive ung isease."— Presentation transcript:

1 G O L D lobal Initiative for Chronic bstructive ung isease

2 http://www.goldcopd.com GOLD Website Address 18/Oct/2005
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. 18/Oct/2005 Dr. David P. Breen

4 Leading Causes of Deaths U.S. 1998
Cause of Death Number 1. Heart Disease ,269 2. Cancer ,947 3. Cerebrovascular disease (stroke) 158,060 4. Respiratory Diseases (COPD) ,381 5. Accidents 94,828 6. Pneumonia and influenza 93,207 7. Diabetes ,574 8. Suicide 29,264 9. Nephritis 26,295 10. Chronic liver disease 24,936 18/Oct/2005 All other causes of death 469,314 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% 18/Oct/2005 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 18/Oct/2005 1960 1965 1970 Dr. David P. Breen 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. 18/Oct/2005 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 In low- and middle-income countries, rates are increasing at an alarming rate. 18/Oct/2005 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 18/Oct/2005 Dr. David P. Breen

10 Clinically apparent disease
Subclinical/ undiagnosed disease 18/Oct/2005 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 18/Oct/2005 Dr. David P. Breen

12 Smoking in Ireland Adults Children and teenagers
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 18/Oct/2005 Dr. David P. Breen

13 Lung Function decline 18/Oct/2005 Dr. David P. Breen

14                                                                                                                               18/Oct/2005 Dr. David P. Breen

15 G O L D lobal Initiative for Chronic bstructive ung isease

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. 18/Oct/2005 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 18/Oct/2005 Dr. David P. Breen

22 Risk Factors for COPD Host Factors Genes (e.g. alpha1-antitrypsin deficiency) Hyperresponsiveness Lung growth Exposure Tobacco smoke Occupational dusts and chemicals Infections Socioeconomic status 18/Oct/2005 Dr. David P. Breen

23 NOXIOUS AGENT (tobacco smoke, pollutants, occupational agent)
Pathogenesis of COPD NOXIOUS AGENT (tobacco smoke, pollutants, occupational agent) COPD Genetic factors Respiratory infection Other 18/Oct/2005 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 18/Oct/2005 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 18/Oct/2005 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 18/Oct/2005 Dr. David P. Breen

30 GOLD Workshop Report Four Components of COPD Management
Assess and monitor disease Reduce risk factors Manage stable COPD Education Pharmacologic Non-pharmacologic Manage exacerbations 18/Oct/2005 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. 18/Oct/2005 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. 18/Oct/2005 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. 18/Oct/2005 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. 18/Oct/2005 Dr. David P. Breen

35 indoor/outdoor pollution
Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation dyspnea indoor/outdoor pollution è SPIROMETRY 18/Oct/2005 Dr. David P. Breen

36 Spirometry: Normal and COPD
18/Oct/2005 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 18/Oct/2005 Dr. David P. Breen

38 Classification by Severity
Stage Characteristics 0: At risk Normal spirometry Chronic symptoms (cough, sputum)  I: Mild FEV1/FVC < 70%; FEV1 ³ 80% predicted With or without chronic symptoms (cough, sputum) II: Moderate FEV1/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 18/Oct/2005 Dr. David P. Breen

39 GOLD Workshop Report Four Components of COPD Management
Assess and monitor disease Reduce risk factors Manage stable COPD Education Pharmacologic Non-pharmacologic Manage exacerbations 18/Oct/2005 Dr. David P. Breen

40 Reduce Risk Factors Key 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 Factors Key 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 Factors Key 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 Factors Key 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
ASK Systematically identify all tobacco users at every visit. ADVISE Strongly urge all tobacco users to quit. ASSESS Determine willingness to make a quit attempt. ASSIST Aid the patient in quitting. ARRANGE Schedule follow-up contact.

45 GOLD Workshop Report Four Components of COPD Management
Assess and monitor disease Reduce risk factors Manage stable COPD Education Pharmacologic Non-pharmacologic Manage exacerbations 18/Oct/2005 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). 18/Oct/2005 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. 18/Oct/2005 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). 18/Oct/2005 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. 18/Oct/2005 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. 18/Oct/2005 Dr. David P. Breen

51 Manage Stable COPD Key Points
Regular treatment with inhaled glucocorticosteroids is appropriate for symptomatic COPD patients with an FEV1 < 50% predicted (Stage III: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations e.g. 3 in the last three years (Evidence A). This treatment has been shown to reduce the frequency of exacerbations and improve health status (Evidence A). 18/Oct/2005 Dr. David P. Breen

52 Manage Stable COPD Key Points
Chronic treatment with systemic glucocortico-steroids should be avoided because of an unfavorable benefit-to-risk ratio (Evidence A). All COPD-patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A). 18/Oct/2005 Dr. David P. Breen

53 Manage Stable COPD Key Points
The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival (Evidence A). 18/Oct/2005 Dr. David P. Breen

54 Management of COPD by Severity of Disease
Stage 0: At risk Stage I: Mild COPD Stage II: Moderate COPD Stage III: Severe COPD Stage IV: Very Severe COPD 18/Oct/2005 Dr. David P. Breen

55 Management of COPD: All stages
Avoidance of risk factors - smoking cessation - reduction of indoor pollution - reduction of occupational exposure Influenza vaccination 18/Oct/2005 Dr. David P. Breen

56 Management of COPD Stage 0: At Risk
Characteristics Recommended Treatment Chronic symptoms - cough - sputum No spirometric abnormalities 18/Oct/2005 Dr. David P. Breen

57 Management of COPD Stage I: Mild COPD
Characteristics Recommended Treatment FEV1/FVC < 70 % FEV1 > 80 % predicted With or without chronic symptoms Short-acting bronchodilator as needed 18/Oct/2005 Dr. David P. Breen

58 Management of COPD Stage II: Moderate COPD
Characteristics Recommended Treatment FEV1/FVC < 70% 50% < FEV1< 80% predicted With or without chronic symptoms Short-acting broncho- dilator as needed Regular treatment with one or more long-acting bronchodilators Rehabilitation 18/Oct/2005 Dr. David P. Breen

59 Management of COPD Stage III: Severe COPD
Characteristics Recommended Treatment FEV1/FVC < 70% 30% < FEV1 < 50% predicted With or without chronic symptoms Short-acting broncho- dilator as needed Regular treatment with one or more long-acting bronchodilators Inhaled glucocortico- steroids if repeated exacerbations Rehabilitation 18/Oct/2005 Dr. David P. Breen

60 Management of COPD Stage IV: Very Severe COPD
Characteristics Recommended Treatment FEV1/FVC < 70% FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure Short-acting bronchodilator as needed Regular treatment with one or more long-acting bronchodilators Inhaled glucocorticosteroids if repeated exacerbations Treat complications Rehabilitation Long-term oxygen therapy if respiratory failure Consider surgical options 18/Oct/2005 Dr. David P. Breen

61 Therapy at Each Stage of COPD
Old (2001) 0: At Risk I: Mild II: Moderate IIA IIB III: Severe New (2003) 0: At Risk I: Mild II: Moderate III: Severe IV: Very Severe Characteristics Chronic Symptoms Exposure to risk factors Normal spirometry FEV1/FVC < 70% FEV1  80% With or without symptoms 50% < FEV1 < 80% 30% < FEV1 < 50% FEV1 < 30% or FEV1 < 50% predicted plus chronic respiratory failure Avoidance of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more long-acting bronchodilators Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments 18/Oct/2005 Dr. David P. Breen

62 GOLD Workshop Report Four Components of COPD Management
Assess and monitor disease Reduce risk factors Manage stable COPD Education Pharmacologic Non-pharmacologic Manage exacerbations 18/Oct/2005 Dr. David P. Breen

63 Manage Exacerbations Key Points
Exacerbations of respiratory symptoms requiring medical intervention are important clinical events in COPD. The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of about one-third of severe exacerbations cannot be identified (Evidence B). 18/Oct/2005 Dr. David P. Breen

64 Manage Exacerbations Key Points
Inhaled bronchodilators (beta2-agonists and/or anticholinergics), theophylline, and systemic, preferably oral, glucocortico-steroids are effective for the treatment of COPD exacerbations (Evidence A). 18/Oct/2005 Dr. David P. Breen

65 Manage Exacerbations Key Points
Patients experiencing COPD exacerbations with clinical signs of airway infection (e.g., increased volume and change of color of sputum, and/or fever) may benefit from antibiotic treatment (Evidence B). 18/Oct/2005 Dr. David P. Breen

66 Manage Exacerbations Key Points
Noninvasive intermittent positive pressure ventilation (NIPPV) in exacerbations improves blood gases and pH, reduces in-hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay (Evidence A). 18/Oct/2005 Dr. David P. Breen

67 Management of COPD In selecting a treatment plan, the benefits and risks to the individual, and the direct and indirect costs to the individual, his or her family, and the community must be considered. 18/Oct/2005 Dr. David P. Breen

68 Take time to think about your lungs……Learn about COPD!
Could it be COPD? Do you know what COPD is? This chronic lung disease is a major cause of illness, yet many people have it and don’t know it. If you answer these questions, it will help you find out if you could have COPD.  1. Do you cough several times most days? Yes ___ No ___  2. Do you bring up phlegm or mucus most days? Yes ___ No ___  3. Do you get out of breath more easily than others your age? Yes ___ No ___  4. Are you older than 40 years? Yes ___ No ___  5. Are you a current smoker or an ex-smoker? Yes ___ No ___ If you answered yes to three or more of these questions, ask your doctor if you might have COPD and should have a simple breathing test. If COPD is found early, there are steps you can take to prevent further lung damage and make you feel better.  Take time to think about your lungs……Learn about COPD! As scientific director of the GOLD program, I will describe some of the steps that are underway to implement this program. 18/Oct/2005 Dr. David P. Breen

69 http://www.goldcopd.com GOLD Website Address 18/Oct/2005
Dr. David P. Breen

70                                                                                                                                                                    18/Oct/2005 Dr. David P. Breen

71 Spirometry is the GOLD Standard for the diagnosis of COPD
18/Oct/2005 Dr. David P. Breen

72 Smoking Cessation Pre-contemplator Relapse contemplation Action
18/Oct/2005 Dr. David P. Breen

73 18/Oct/2005 Dr. David P. Breen

74 Pharmacological treatment
1st line treatment Nicotine replacement Nicotine polacrilex (gum) Transdermal nicotine Nicotine inhaler Nicotine nasal spray Nicotine lozenges Combined modality Bupropion 2nd line treatment Clonidine Nortripyline 18/Oct/2005 Dr. David P. Breen

75 Management of Stable Disease
Smoking cessation Pharmacological treatment LTOT Pulmonary rehabilitation Surgery 18/Oct/2005 Dr. David P. Breen

76 Pharmacological therapy
Medications can reduce or abolish symptoms,increase exercise tolerance,reduce no and severity of symptoms and improve health status No treatment alters the rate of decline of lung function Inhaled route is preferable – smaller doses and therefore reduced side effects by inhalation Combining agents have a greater effect on symptoms than single agents 18/Oct/2005 Dr. David P. Breen

77 General principles Patients must be educated in the device
Choose right device for patient – MDI v DPI v Spacer device Spacer good for delivery and reduce oral s/e Compliance is variable – studies show at east 85% of patients take 70% of the prescribed doses - ? Reflect the constant symptoms Education is essential for good adherence and proper use Spirometry essential for diagnosis but not for monitoring 18/Oct/2005 Dr. David P. Breen

78 Bronchodilators Β2 agonist Anticholinergic agents Methylxanthines
Mode of action is smooth muscle relaxation – small changes in FEV but decreases in lung volumes resulting in better emptying and less hyperinflation 18/Oct/2005 Dr. David P. Breen

79 Β2 agonist Inhaled (short , long acting), oral Mode of action S/E
Increase in c-amp within cells and promote smooth muscle relaxation ?other non bronchodilator effects S/E Palpitations, PVC Tremor Sleep disturbance Metabolic - hypokalaemia 18/Oct/2005 Dr. David P. Breen

80 Anticholinergic drugs
Only available via inhaled route Ipratropium Oxitropium Tiotropium Inhibit muscarinic receptors Tiotropium remains bound to receptors for up to 36 hours Onset of bronchodilatation in 30 mins S/E Not associated with significant incidence of prostatism or cardiac S/E Commonest – dry mouth(tiotropium), metallic taste (ipratropium), closed angle glaucoma 18/Oct/2005 Dr. David P. Breen

81 Methylxanthines Oral or I.V prn preparations
Non specific PDE inhibitors and increase c-amp Bronchodilatation only occurs at high dose and narrow therapeutic/toxic window Keep at level of 8-14 ug.dl Can be bd or od drugs S/E Major – ventricular and atrial rhythm disturbance, convulsions Minor – headache, nausea, vomiting, diarrhoea and heartburn 18/Oct/2005 Dr. David P. Breen

82 Anti-convulsant drugs rifampicin
Levels increased Levels decreased Respiratory acidosis CCF Liver cirrhosis Erthyromycin ciprofloxacin Cigarette smoke Anti-convulsant drugs rifampicin 18/Oct/2005 Dr. David P. Breen

83 Glucocorticoids Inhalation Oral Beclomethasone Budesonide
Triamcinolone Fluticasone Flunisolide Oral Not indicated in stable – excessive S/E profile 18/Oct/2005 Dr. David P. Breen

84 Pharmacology S/E Clinical outcomes
Effect transcription processes – slow action High dose can be absorbed via the pulmonary circulation S/E Oral – osteoporosis, cataracts, peripheral myopathy Topical/local S/E can be significant Skin bruising Clinical outcomes If FEV<50% and a number of exacerbations/year rate of deterioration in health status can be reduced 3 year prospective studies revealed no effect on rate of decline of FEV1 18/Oct/2005 Dr. David P. Breen

85 Combination therapy Combination treatment is a convenient, safe and improves compliance Initial data show a significant effect on pulmonary function and a reduction in symptoms Largest effects in most severe – FEV<50% and a number of exacerbations 18/Oct/2005 Dr. David P. Breen

86 Other agents Mucolytic agents – carbocysteine, iodinated glycerol
Little evidence of any effect on lung function Cochrane review – supports a role for reducing no of exacerbations in chronic bronchitis N-acetylcysteine – at present prospective study ongoing 18/Oct/2005 Dr. David P. Breen

87 Leukotreine receptor antagonist -No data to support role
Maintenance antibiotic –no data to suggest that these drugs are effective in modifying symptoms, exacerbations or lung function Respiratory stimulants – oral peripheral chemoreceptor stimulant – improves V/Q matching and improves oxygenation – can result in peripheral neuropathy Vaccination Influenza – can reduce serious illness and death by 50% Pneumococcal – reduces bacteraemia 18/Oct/2005 Dr. David P. Breen

88 Alpha1-antitrypsin deficiency
Augmentation therapy Licensed for i.v. use twice a week Expensive No RCT showing benefit Suggestio that rate of decline in those receiving drug is less than historical controls. 18/Oct/2005 Dr. David P. Breen

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