World COPD Day 2005 Slide Kit A presentation about chronic obstructive pulmonary disease (COPD), its diagnosis, prevention, and treatment. This presentation consists of excerpts from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) teaching slide set. The full slide set is available at www.goldcopd.org.

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.

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.

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.

Burden of COPD Mortality 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.

Leading Causes of Deaths U.S., 2002 Cause of Death Number 1. Heart Disease 695,754 2. Cancer 558,847 3. Cerebrovascular disease (stroke) 163,010 4. COPD and allied conditions 125,500 5. Accidents 102.303 6. Diabetes 73,119 7. Influenza and pneumonia 65,984 8. Alzheimer’s disease 58,785 9. Nephritis 41,018 10. Septicemia 33,881 All other causes of death 529,661 Source: NHLBI, NIH, DHHS

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% 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 Source: NHLBI/NIH/DHHS

Future Mortality Worldwide 1990 2020 Ischemic heart disease Cerebrovascular disease Lower resp infection Diarrheal disease Perinatal disorders COPD Tuberculosis Measles Road traffic accidents Lung cancer 3rd 6th Stomach Cancer HIV Suicide Murray & Lopez. Lancet 1997

Burden of COPD Economic Burden 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.

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

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

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

NOXIOUS AGENT (tobacco smoke, pollutants, occupational agent) Pathogenesis of COPD NOXIOUS AGENT (tobacco smoke, pollutants, occupational agent) COPD Genetic factors Respiratory infection Other

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

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

GOLD Workshop Report Four Components of COPD Management Assess and monitor disease Reduce risk factors Manage stable COPD Education Pharmacologic Non-pharmacologic Manage exacerbations 2005 5

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

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.

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.

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.

indoor/outdoor pollution Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation dyspnea indoor/outdoor pollution è SPIROMETRY

Spirometry: Normal and COPD

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

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

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).

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).

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.

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).

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.

Manage Stable COPD Key Points 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). All COPD-patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A).

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. 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.

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).

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.

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.

Glucocorticosteroids in Stable COPD 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). Inhaled glucocorticosteroid combined with a long-acting B2-agonist is more effective than the individual components (Evidence A).

Glucocorticosteroids in Stable COPD Chronic treatment with systemic glucocortico-steroids should be avoided because of an unfavorable benefit-to-risk ratio (Evidence A).

Oxygen Therapy in Stable COPD The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival (Evidence A).

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

Management of COPD: All stages Avoidance of risk factors - smoking cessation - reduction of indoor pollution - reduction of occupational exposure Influenza vaccination

Management of COPD Stage 0: At Risk Characteristics Recommended Treatment Chronic symptoms - cough - sputum No spirometric abnormalities

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

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

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

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

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

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).

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).

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).

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).

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.

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.