1. Gestione clinica della BPCO1

2. Obiettivi della gestione della BPCO
PATIENT CHARACTERISTICS
Prevent and treat symptoms Prevent and treat exacerbations
Improve exercise tolerance Prevent and treat complications
Improve health status Prevent disease progression
Reduce mortality
Speaker notes
GOLD’s Global strategy for the diagnosis, management, and prevention of COPD proposes four major components of COPD management:
Assess and monitor disease
Reduce risk factors
Manage stable COPD
Manage exacerbations
These terms reflect current disease state, which may have beneficial effects in the future. However, there is no clear distinction between current and future management goals with respect to today’s implementation and future risk reduction. These 4 components in turn encompass the seven goals of COPD management which some have may have more impact on the current state whereas others may have an impact on the future.
GOLD recommends a range of non-pharmacological and pharmacological treatments to help achieve these goals. Progressive introduction of new treatments is recommended to prevent further deterioration of lung function.
Reference
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD
Postma D, Anzueto A, Calverley P, et al. A new perspective on optimal care for patients with COPD. Prim Care Respir J 2011; 20:
MANAGEMENT PLAN
Adapted from 1. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) Available from w2.Postma D, Anzueto A, Calverley P, et al . Prim Care Respir J 2011; 20: 2

3. Cessazione del fumo di sigaretta e declino del FEV1
100
Smoked regularly and susceptible to its effects
Never smoked or not susceptible to smoke 75
Disability
FEV1 (% of value at age 25) 50
Stopped at 45
Disability
Speaker notes
Stopping smoking is the single most effective way of slowing the decline in lung function in patients at all stages of COPD.1
This is true for all patients who are at risk, from those with no current symptoms to those with severe disease.
Patients who continue to smoke will lose lung function at a rapid rate whereas those who stop smoking will deteriorate more slowly.
However, lost lung function cannot be regained and chronic inflammation may persist for many years after the patient stops smoking.2-4
Other non-pharmacologic treatments for COPD include pulmonary rehabilitation, oxygen therapy and, for very severe disease, lung volume reduction surgery.
References
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD
Fletcher C and Peto R. The natural history of chronic airflow obstruction. BMJ 1977;1645–1648.
Hogg J. Why does airway inflammation persist after the smoking stops. Thorax 2006;61:96–97.
Gamble E, Grootendorst DC, Hattotuwa K, et al. Airway mucosal inflammation in COPD is similar in smokers and ex-smokers: a pooled analysis. Eur Respir J 2007;30:467–471. 25
Death
Stopped at 65
Age (years) 25 50 75
Adapted from Fletcher C , Peto R. BMJ 1977;1: 3

4. Trattamento farmacologico in relazione alla gravità della malattia
Add long-term oxygen if chronic respiratory failure
Consider surgical procedures
Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
Stage III: Severe
Stage IV: Very Severe
Stage II: Moderate
Stage I: Mild
FEV1/FVC<0.70
FEV1 ≥80% predicted
50% FEV1 <80% predicted
30% FEV1 <50% predicted
FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure
Add inhaled glucocorticosteroids if repeated exacerbations
Speaker notes
GOLD identifies four stages of COPD severity, each defined by the FEV1 measurement obtained using spirometry, and the frequency of exacerbations.
During Stage I (‘Mild’), treatment with a short-acting bronchodilator (SABA), given as needed, is sufficient for relief of persistent or worsening symptoms.
As COPD progresses, (Stage II, ‘Moderate’) the addition of regular treatment with a long-acting bronchodilator is recommended.
In the later stages of COPD (Stages III and IV, ‘Severe’ to ‘Very Severe’), and if repeated exacerbations, addition of an inhaled corticosteroid is recommended
Reference
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010
Available from 4

5. Global Strategy for Diagnosis, Management and Prevention of COPD Opzioni terapeutiche per la BPCO
Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors 5

6. Una nuova prospettiva di ‘cura ottimale’ per il paziente con BPCO
PATIENT CHARACTERISTICS
MANAGEMENT PLAN
FUTURE RISK REDUCTION
BEST CURRENT CONTROL
Speaker notes
Very recently a new paradigm for the management of COPD has been proposed. This is based on the concept that ‘here-and-now’ goals to minimise current impact on an individual patient should be integrated with goals to achieve better long-term outcomes and reduce future risks.
The terminologies introduced in this concept paper are – ‘optimal COPD care’, ‘best current control’, and ‘future risk reduction’ reflecting the concept that , to a COPD patient, prevention of future risk is of equal importance to the immediate impact of treating symptoms.
The impact an intervention may have on long-term disease progression is sometimes independent of any effect it may have on current symptoms.
Clinicians already apply this broader approach to risk factors such as hypertension and hypercholesterolaemia. Treatments that reduce high blood pressure and serum cholesterol are nowadays prescribed independently of any acute effects on current symptoms. It has now been suggested that this approach should also be considered in COPD.
Exacerbations can be used as an example of the link between best current control and future risk reduction. Exacerbation frequency has been linked to increased disease progression in COPD. Recent studies suggest that future exacerbation risk is related to previous exacerbation history. Current therapies are known to decrease the frequency of these future exacerbation events. Thus, treatment reducing exacerbation-frequency can exemplify why current treatment is warranted independent of its impact on ‘best current control’ and rather as a target for ‘future risk reduction’.
Reference
Postma D, Anzueto A, Calverley P, et al. A new perspective on optimal care for patients with COPD. Prim Care Respir J 2011; 20:
Postma D, Anzueto A, Calverley P, et al. Prim Care Respir J 2011; 20: 6

7. Concetti chiave
COPD is diagnosed based on medical history, exposure to risk factors and assessment of lung function by spirometry
Recently it has been suggested that ‘optimal care’ should focus on both ‘best current control’, and ‘future risk reduction’ reflecting the concept that prevention of future risk is of equal and complementary importance to a COPD patient as the immediate impact of treating symptoms
GOLD guidelines recommend stepwise addition of pharmacological treatments based on lung function impairment and exacerbation history 7