1. 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

2. 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.

3. 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.

4. 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.

5. 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.

6. Leading Causes of Deaths U.S., 2002
Cause of Death Number 1.
Heart Disease ,754 2.
Cancer ,847 3.
Cerebrovascular disease (stroke) 163,010 4.
COPD and allied conditions ,500 5.
Accidents 6.
Diabetes 73,119 7.
Influenza and pneumonia ,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

7. 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%
Source: NHLBI/NIH/DHHS

8. 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

9. 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.

10. 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

11. 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.

12. 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

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

17. 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. 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

19. 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

20. 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

21. 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.

22. 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.

23. 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.

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

25. Spirometry: Normal and COPD

26. 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

27. 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

28. 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).

29. 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).

30. 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.

31. 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).

32. 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.

33. 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).

34. 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.

35. 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).

36. 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.

37. 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.

38. 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).

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

40. 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).

41. 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

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

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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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).

50. 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).

51. 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).

52. 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).

53. 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.

54. 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.