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

2. Global Initiative for Chronic Obstructive Lung Disease
In collaboration with:
National Heart, Lung, and Blood Institute, NIH
and
World Health Organization

3. GOLD Executive Committee
R. Pauwels, Belgium – Chair
S. Buist, US C. Jenkins, Australia
P. Calverley, UK N. Khaltaev, Switzerland
B. Celli, US C. Lenfant, US
Y. Fukuchi, Japan J. Luna, Guatemala
S. Hurd, US W. MacNee, UK
L. Grouse, US N. Zhong, China

4. GOLD Expert Panel R. Pauwels, Belgium Chair
N. Anthonisen, Canada C. Jenkins, Australia
W. Bailey, US D. Postma, Netherlands
P. Barnes, UK K. Rabe, Netherlands
S. Buist, US S. Ramsey, US
P. Calverley, UK S. Rennard, US
T. Clark, UK R. Rodriguez-Roisin, Spain
L. Fabbri, Italy N. Siafakas, Greece
Y. Fukuchi, Japan S. Sullivan, US
J. Hogg, Canada W. Tan, Singapore

5. GOLD Sponsors ASTA Medica Merck Sharp & Dohme
AstraZeneca Mitsubishi-Tokyo
Aventis Nikken Chemicals
Bayer Novartis
Boehringer-Ingelheim Schering-Plough
Byk Gulden Yamanouchi
Chiesi Zambon
GlaxoSmithKline

6. 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.

7. 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
All other causes of death 469,314

8. 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%

9. Age-Adjusted Death Rates for COPD, U.S., 1960-1995
Deaths per 100,000 60 50 40 30 20 10
1960
1965
1970
1975
1980
1985
1990
1995
2000

10. Facts About COPD
Between 1985 and 1995, the number of physician visits for COPD in the United States increased from 9.3 million to 16 million.
The number of hospitalizations for COPD in 1995 was estimated to be 500, Medical expenditures amounted to an estimated $14.7 billion.

11. COPD 1990 Prevalence Male/1000 Female/1000
Established Market Economies
Formerly Socialist Economies
India
China
Other Asia and Islands
Sub-Saharan Africa
Latin America and Caribbean
Middle Eastern Crescent
World
*From Murray & Lopez, 1996

12. Facts About COPD
Between 1985 and 1995, the number of physician visits for COPD in the United States increased from 9.3 million to 16 million.
The number of hospitalizations for COPD in 1995 was estimated to be 500, Medical expenditures amounted to an estimated $14.7 billion.

13. Physician Office Visits for Chronic and Unspecified Bronchitis, U.S.
Number (Millions) 15 10 5
1980
1985
1990
1995
1998
Year
Source: National Ambulatory Medical Care Survey, NCHS

14. 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.

15. Facts About COPD
In India, it is estimated that thousand premature deaths can be attributed annually to use of biomass fuels, placing indoor air pollution as a major risk factor in the country.
In Algeria, the prevalence of tuberculosis and acute respiratory infections has decreased since 1965; an increase in COPD and asthma has been observed in the last decade.

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

17. GOLD Objectives
Increase awareness of COPD among health professionals, health authorities, and the general public
Improve diagnosis, management, and prevention
Stimulate research

18. GOLD Documents
Workshop Report: Global Strategy for the Diagnosis, Management, and Prevention of COPD
Executive Summary
Pocket Guide for health care providers
Guide for patients and their families (available late 2001)

19. GOLD Workshop Report Evidence-based Implementation oriented Diagnosis
Management
Prevention
Outcomes can be evaluated

20. GOLD Workshop Report Evidence category Sources of evidence
A Randomized clinical trials
Rich body of data
B Randomized clinical trials
Limited body of data
  C Non randomized trials
Observational studies
 D Panel judgment consensus

21. GOLD Workshop Report: Contents
Introduction
Definition and classification
Burden of COPD
Risk factors
Pathogenesis, pathology, and pathophysiology
Management
Future research

22. 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.

23. 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.

24. 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.

25. 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.

26. Direct and Indirect Costs of COPD, 1993 (US $ Billions)
Direct Medical Cost: $14.7
Total Indirect Cost: $ 9.2
Mortality related IDC 4.5
Morbidity related IDC 4.7
Total Cost $23.9

27. 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

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

32. 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

33. 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

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

35. 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

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

37. 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.

38. 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.

39. 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.

40. 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.

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

42. Spirometry: Normal and COPD

43. 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

44. 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 symptoms (cough, sputum)
II: Moderate FEV1/FVC < 70%; 30% £ FEV1 < 80% predicted
(IIA: 50% £ FEV1 < 80% predicted;
IIB: 30% £ FEV1 < 50% predicted)
With or without chronic symptoms (cough, sputum, dyspnea)
III: Severe FEV1/FVC < 70%; FEV1 < 30% predicted or FEV1 < 50%predicted plus respiratory failure or clinical signs of right heart failure

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

47. 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).

48. 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).

49. 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.

50. 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).

51. 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.

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

53. 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).

54. 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.

55. 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).

56. 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 symptoms relief and side effects.

57. Bronchodilators in Stable COPD
Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms.
Long-acting inhaled bronchodilators are more convenient.
Combining bronchodilators may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.

58. Manage Stable COPD Key Points
Regular treatment with inhaled glucocortico-steroids should only be prescribed for symptomatic COPD patients with a documented spirometric response to glucocorticosteroids or in those with an FEV1 < 50% predicted and repeated exacerbations requiring treatment with antibiotics and/or oral glucocorticosteroids (Evidence B).

59. 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).

60. 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).

61. Management of COPD by Severity of Disease
Stage 0: At risk
Stage 1: Mild COPD
Stage 2: Moderate COPD
Stage 3: Severe COPD

62. Management of COPD: All stages
Avoidance of noxious agents
- smoking cessation
- reduction of indoor pollution - reduction of occupational exposure
Influenza vaccination

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

64. Management of COPD Stage I: Mild COPD
Characteristics Recommended Treatment
FEV1/FVC < 70 %
FEV1 > 80 % predicted
With or without symptoms
Short-acting bronchodilator as needed

65. Management of COPD Stage IIA: Moderate COPD
Characteristics Recommended Treatment
FEV1/FVC < 70%
50% < FEV1< 80% predicted
With or without symptoms
Regular treatment with one or more bronchodilators
Rehabilitation
Inhaled glucocortico-steroids if significant symptoms and lung function response

66. Management of COPD Stage IIB: Moderate COPD
Characteristics Recommended Treatment
FEV1/FVC < 70%
30% < FEV1 < 50% predicted
With or without symptoms
Regular treatment with one or more bronchodilators
Rehabilitation
Inhaled glucocortico-steroids if significant symptoms and lung function response or if repeated exacerbations

67. Management of COPD Stage III: Severe COPD
Characteristics Recommended Treatment
FEV1/FVC < 70%
FEV1 < 30% predicted or presence of respiratory failure or right heart failure
Regular treatment with one or more bronchodilators
Inhaled glucocorticosteroids if significant symptoms and lung function response or if repeated exacerbations
Treatment of complications
Rehabilitation
Long-term oxygen therapy if respiratory failure
Consider surgical options

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

69. 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).

70. 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).

71. 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)

72. Manage Exacerbations Key Points
Noninvasive intermittent positive pressure ventilation (NIIPPV) in acute 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).

73. 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.

74. GOLD Website Address