1. New Guidelines for COPD They keep changing. . . are you up to speed?by
Scott Cerreta, BS, RRT
Director of Education

2. Conflict of Interest
I have no real or perceived conflict of interest that relates to this presentation. Any use of brand names is not in any way meant to be an endorsement of a specific product, but to merely illustrate a point of emphasis.

3. Objectives Discuss different definitions of COPD
Discuss current literature and research that warrants the need to change COPD Guidelines
Describe new features of the GOLD Guidelines
Describe how these changes will impact diagnosis and treatment recommendations

4. 1. GOLD Definition
COPD, a common preventable and treatable disease, is characterized by persistent 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.
Exacerbations and comorbidities contribute to the overall severity in individual patients.

5. ATS / ERS Definition
Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible.
The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.

6. NHLBI Definition Chronic Obstructive Pulmonary Disease
Serious lung disease that over time makes it hard to breathe
Emphysema
Chronic Bronchitis
Blocked (obstructed) airways make it hard to get air in and out
So what is COPD? It stands for Chronic Obstructive Pulmonary Disease.
COPD is a serious lung disease that progresses slowly and over time, makes it very difficult to breathe. You may also have heard it called by other names. Emphysema and chronic bronchitis are forms of COPD. COPD is a general term that includes a spectrum of diseases. Very often a doctor may say “you have emphysema” when the person has elements of both emphysema and chronic bronchitis. In fact, it is common for people to have elements of both, which is why we prefer the term COPD. In people who have COPD, the airways, or tubes that carry air from the nose and mouth into the lungs, are partially blocked—either because of thickening and mucus, or because the airways are floppy and collapse, or both.

7. COPD Foundation Definition
Chronic Obstructive Pulmonary Disease
Serious lung disease that over time makes it hard to breathe
Emphysema
Chronic Bronchitis
Refractory Asthma and
Some forms of bronchiectasis
Blocked (obstructed) airways make it hard to get air in and out
So what is COPD? It stands for Chronic Obstructive Pulmonary Disease.
COPD is a serious lung disease that progresses slowly and over time, makes it very difficult to breathe. You may also have heard it called by other names. Emphysema and chronic bronchitis are forms of COPD. COPD is a general term that includes a spectrum of diseases. Very often a doctor may say “you have emphysema” when the person has elements of both emphysema and chronic bronchitis. In fact, it is common for people to have elements of both, which is why we prefer the term COPD. In people who have COPD, the airways, or tubes that carry air from the nose and mouth into the lungs, are partially blocked—either because of thickening and mucus, or because the airways are floppy and collapse, or both.

8. COPD: Definitions of 21st Century1
Preventable and treatable
Airflow limitation that is not fully reversible
Progressive disease
Abnormal inflammatory response of the lungs
Subsets of patients
Chronic bronchitis
Emphysema
Alpha-1 Deficiency
Bronchiectasis
COPD
O2 Dependency
OSA, HTN, Others
COPD is a general term used to describe a group of patients that suffer from this largely tobacco-causing illness.
Three circles represents a more realistic representation of patients suffering from COPD. Many patients have components of both Chronic bronchitis and emphysema as a result of environmental exposures.
Patients with asthma and exposure to ETS are more likely to develop symptoms of COPD.
COPD is: Read Slide
Asthma
Box = FEV1/FVC < 70% or < LLN
Spirometry is REQUIRED for diagnosis

9. 2. Literature Review COPD Gene Study – Dr. Crapo
Why some smokers get COPD & others don’t
Using HRCT and identified a large number of people with emphysema despite normal spirometry
Spiromics – Dr. Rennard
Identifying subsets of people with COPD
collection and analysis of phenotypic, biomarker, genetic, genomic, and clinical data from subjects with COPD

10. Observations from Experts
Not all forms of Emphysema or Chronic Bronchitis are COPD.
Not all severities of COPD are the same
People with same FEV1 have different health status, dyspnea scores, comorbidities, exacerbation history, etc.

11. Dr. Vesbo, Chair of GOLD states:
“Spirometry is essential for the diagnosis of COPD, but it doesn’t fully capture the impact of the disease on individual patients”
Example: Some patients with Moderate COPD may have severe breathlessness, while others may have Mild COPD but more prone to acute exacerbations
Both groups require more aggressive therapy than past guidelines would recommend

12. “COPD HETEROGENEITY” Cote & Celli PT # 1 58 y FEV1: 28 % MRC: 2/4
PaO2: 70 mmHg
6MWD: 540 m
BMI: 30
PT # 2
62 y
FEV1: 33%
MRC: 2/4
PaO2: 57 mmHg
6MWD: 400 m
BMI: 21
PT # 3
69 y
FEV1: 35%
MRC: 3/4
PaO2: 66 mmHg
6MWD: 230 m
BMI: 34
PT # 4
72 y
FEV1: 34%
MRC: 4/4
PaO2: 60 mmHg
6MWD: 154 m
BMI: 24

13. GOLD Treatment of COPD FEV1 / FVC < 70% I: Mild II:Moderate
FEV1>80% pred
II:Moderate
FEV % pred
III: Severe
FEV % pred
IV: Very Severe
FEV1 < 30% pred or FEV1 <50% predicted plus respiratory failure
Active Reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator when needed
Add regular treatment with one or more long-acting bronchodilators: ß2 agonists and anticholinergics
Add rehabilitation
Add ICS for repeated exacerbations
Add LTOT
Surgical interventions
Recommended Progression of COPD Pharmacotherapy Key Points
The chart in this slide summarizes the medications used most often in the treatment of patients with COPD and the stages at which they are most likely to be introduced. As mentioned in the previous slide, therapy should be tailored to match individual patient symptoms. The progression shown here is intended to provide guidance early.
Stage I: short-acting inhaled therapy as needed to control dyspnea or coughing spasms is usually sufficient.
Stages II-IV: patients whose symptoms are not adequately controlled with as-needed short-acting bronchodilators should receive regular treatment with a long-acting inhaled bronchodilator.
Patients with Stages II-IV who are on regular short- or long-acting bronchodilator therapy may also use a short-acting bronchodilator as needed. Some patients may request regular treatment with high-dose nebulized bronchodilators, especially if they have experienced subjective benefit from this treatment during an acute exacerbation.
Stages III-IV: regular treatment with inhaled corticosteroids (ICS) is warranted in patients with a postbronchodilator FEV1 <50% predicted and a history of repeated exacerbations (for example, 3 in the last 3 years). This should be added to regular bronchodilator treatment.
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease Updated Available at:

14. 3. New Features Added in Dec 2011
GOLD Spirometry Classification Stays
NEW is Assessment Model – ABCD
mMRC dyspnea scale or COPD Assessment Test (CAT) health status
Spirometry classification and
Exacerbation History

15. Assess degree of airflow limitation using spirometry
Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using spirometry
Assess risk of exacerbations
Assess comorbidities

16. (C) (D) (B) (A) Risk Risk Symptoms
Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD 4
(C)
(D)
> 2 3
(Exacerbation history)
Risk
(GOLD Classification of Airflow Limitation)
Risk 2
(A)
(B) 1 1
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))

17. Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of Symptoms
COPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD (
Breathlessness Measurement using the Modified British Medical Research Council (mMRC) Questionnaire: relates well to other measures of health status and predicts future mortality risk.

18. Tools: COPD Assessment Test (CAT)
Measures health status
Based on 8 questions
Score from 0 to 5
High scores = symptoms
May predict exacerbation
May reveal improvement after attending Rehab

19. Global Strategy for Diagnosis, Management and Prevention of COPD Modified MRC (mMRC)Questionnaire

20. Assess symptoms first (C) (D) (A) (B) If mMRC 0-1 or CAT < 10:
Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD
Assess symptoms first
If mMRC 0-1 or CAT < 10:
Less Symptoms (A or C)
If mMRC > 2 or CAT > 10:
More Symptoms (B or D)
(C)
(D)
(A)
(B)
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))

21. In patients with FEV1/FVC < 0.70:
Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1 > 80% predicted
GOLD 2: Moderate % < FEV1 < 80% predicted
GOLD 3: Severe % < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1

22. Global Strategy for Diagnosis, Management and Prevention of COPD Assess Risk of Exacerbations
To assess risk of exacerbations use history of exacerbations and spirometry:
Two or more exacerbations within the last year or an FEV1 < 50 % of predicted value are indicators of high risk.

23. Tease Out All Exacerbations
Must assess all exacerbations – increase in symptoms that requires change in tx
Hospitalizations
ER / Urgent Care visits
PCP / Pulmonologist visit
Ask about infection or use of antibiotics, the most common cause of exacerbation

24. Assess risk of exacerbations next
Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD
Assess risk of exacerbations next
If GOLD 1 or 2 and only
0 or 1 exacerbations per year:
Low Risk (A or B)
If GOLD 3 or 4 or two or
more exacerbations per year:
High Risk (C or D) 4
(C)
(D)
> 2 3
(GOLD Classification of Airflow Limitation)
Risk
(Exacerbation history)
Risk 2 1
(A)
(B) 1
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))

25. Use combined assessment
Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD
Use combined assessment
Patient is now in one of
four categories:
A: Less symptoms, low risk
B: More symptoms, low risk
C: Less symptoms, high risk
D: More symptoms, high risk
> 2 1
(C)
(D)
(A)
(B)
mMRC 0-1
CAT < 10 4 3 2
mMRC > 2
CAT > 10
(GOLD Classification of Airflow Limitation)
Risk
(Exacerbation history)
Risk
Symptoms
(mMRC or CAT score))

26. Spirometric Classification Exacerbations per year
Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD
When assessing risk, choose the highest risk according to GOLD grade or exacerbation history
Patient
Characteristic
Spirometric Classification
Exacerbations per year
mMRC
CAT A
Low Risk
Less Symptoms
GOLD 1-2
≤ 1
0-1
< 10 B
More Symptoms
> 2
≥ 10 C
High Risk
GOLD 3-4 D

27. Maintenance Care vs. Acute Care
Typical hospitalization requires aggressive medication management
Goal is to return patient to baseline treatment recommendations
Maintenance Therapy requires the least amount of medication to control patient symptoms and health status

28. *ICS+LABA and *PDE4-inh. or
Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy (Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.)
Patient
First choice
Second choice
Alternative Choices A
SAMA prn or
SABA prn
*LAMA
LABA
SABA and SAMA
Theophylline B
*LAMA and LABA
SABA and/or SAMA C
*ICS + LABA
*PDE4-inh. D
ICS and *LAMA or
*ICS + LABA and *LAMA or
*ICS+LABA and *PDE4-inh. or
*LAMA and LABA or
*LAMA and *PDE4-inh.
Carbocysteine

29. Consequences Of COPD Exacerbations
Negative
impact on
quality of life
Impact on
symptoms
and lung
function
EXACERBATIONS
Accelerated
lung function
decline
Increased
economic
costs
Increased
Mortality

31. Scenario 1 Step 1: assess mMRC or CAT. mMRC=1
Left side, less symptoms
Step 2: assess spirometry = FEV1 43%
assess exacerbation hx = 2
Upper side, high risk
Assessment Score = C

32. Scenario 1 Old GOLD Recommended Tx New GOLD Recommended Tx FEV1 = 43%
Severe Stage 3
Recommended Tx
LABA or LAMA or LABA + LAMA
ICS
New GOLD
FEV1 = 43%, Group C Less symp, Hi risk
Recommended Tx
ICS + LABA or LAMA
PDE4 inh.

33. Scenario 2 Step 1: assess mMRC or CAT. CAT=12
Right side, more symptoms
Step 2: assess spirometry = FEV1 81%
assess exacerbation hx = 0
Lower side, Low risk
Assessment Score = B

34. Scenario 2 Old GOLD Recommended Tx New GOLD Recommended Tx FEV1 = 81%
Mild Stage 1
Recommended Tx
SABA prn
New GOLD
FEV1 = 81%, Group B More symp, Low risk
Recommended Tx
LAMA or LABA

35. Scenario 3 Step 1: assess mMRC or CAT. mMRC=4
Right side, more symptoms
Step 2: assess spirometry = FEV1 56%
assess exacerbation hx = 5
Upper side, High risk
Assessment Score = D

36. Scenario 3 Old GOLD Recommended Tx New GOLD Recommended Tx FEV1 = 56%
Moderate Stage 2
Recommended Tx
SABA prn
LABA or LAMA or LABA + LAMA
New GOLD
FEV1 = 56%, Group D More symp, Hi risk
Recommended Tx
ICS + LABA or LAMA
PDE4 inh.
Add everything else

37. Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Summary
Prevention of COPD is to a large extent possible and should have high priority
Spirometry is required to make the diagnosis of COPD; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD
The beneficial effects of pulmonary rehabilitation and physical activity cannot be overstated

38. “COPD HETEROGENEITY” Cote & Celli PT # 1 58 y FEV1: 28 % MRC: 2/4
PaO2: 70 mmHg
6MWD: 540 m
BMI: 30
PT # 2
62 y
FEV1: 33%
MRC: 2/4
PaO2: 57 mmHg
6MWD: 400 m
BMI: 21
PT # 3
69 y
FEV1: 35%
MRC: 3/4
PaO2: 66 mmHg
6MWD: 230 m
BMI: 34
PT # 4
72 y
FEV1: 34%
MRC: 4/4
PaO2: 60 mmHg
6MWD: 154 m
BMI: 24

39. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Rehabilitation
All COPD patients benefit from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigue.
Although an effective pulmonary rehabilitation program is 6 weeks, the longer the program continues, the more effective the results.
If exercise training is maintained at home the patient's health status remains above pre- rehabilitation levels.

40. COPD Pocket Consultant

41. Mobile App – Coming Soon

42. Summary
Dx of COPD requires Spirometry but definitions vary and change with new evidence
Tx of COPD requires new assessment
Spirometry, dyspnea score, exacerbation hx and consider comorbidities
New ABCD assessment model is more accurate and will improve pt outcomes
Learn how you can implement this model into your system to decrease hospitalization rates
As you can see, the key to self-managing COPD is more than just taking medicine. It involves a good COPD Action Plan to Optimize Care. Those with Optimal Care will be rewarded with the best quality of Life.
In order to know what is recommended for Optimal Care, it starts with learning your FEV1 value and the Stage of COPD that you have. We recommend that patients ask for an annual spirometry test on a good day. And, know your FEV1 !
You will be glad you did.
Next slide is Thank You

43. COPD is: Almost Always Preventable. Almost Always Treatable
COPD is: Almost Always Preventable. Almost Always Treatable. Someday Curable.
Thank You !
Any Questions?

44. References

45. References
GOLD Guidelines
COPD Gene Study
Spiromics
COPD Foundation