how to make money by selling simple items made in self-suficcient home industries

7/28/2019 how to make money by selling simple items made in self-suficcient home industries

1/115

Global Initiative for Chronic Obstructive Lung Disease

GLOBAL INITIATIVE FOR CHRONIC

OBSTRUCTIVE LUNG DISEASE (GOLD):TEACHING SLIDE SET

December 2011This slide set is restricted for academic and educational

purposes only. Use of the slide set, or of individualslides, for commercial or promotional purposes requiresapproval from GOLD.


2/115

lobal Initiative for Chronic

bstructive

ung

isease

GO

L

D Global Initiative for Chronic Obstructive Lung Disease


3/115

GOLD Structure

GOLD Board of Directors

Roberto Rodriguez-Roisin, MDChair

Science Committee

Jrgen Vestbo, MD - Chair

Dissemination/Implementation

CommitteeJean Bourbeau, MD - Chair


4/115

GOLD Board of Directors: 2011

R. Rodriguez-Roisin,Chair, Spain

A. Anzueto, U.S. [ATS]

J. Bourbeau, Canada

T. DeGuia, Philippines

D. Hui, Hong Kong PRC

F. Martinez, U.S.

M. Mishima, Japan[APSR]

D. Nugmanova, Kazakhstan

[WONCA]

A. Ramirez, Mexico[ALAT]

R. Stockley, U.K.

J. Vestbo, Denmark, U.K.

Observer: J. Wedzica, UK[ERS]


5/115

GOLD Science Committee - 2011

Jrgen Vestbo, MD, Chair

AlvarAgusti, MD

Antonio Anzueto, MD

Peter Barnes, MD

Leonardo Fabbri, MD

Paul Jones, MD

Fernando Martinez, MD

Masaharu Nishimura, MD

Roberto Rodriguez-Roisin, MD

Don Sin, MD

Robert Stockley, MDClaus Vogelmeier, MD


6/115

EvidenceCategory

Sources of Evidence

A Randomized controlled trials(RCTs). Rich body of data

B Randomized controlled trials(RCTs). Limited body of data

C Nonrandomized trialsObservational studies.

D Panel consensus judgment

Description of Levels of Evidence


7/115

GOLD Structure

GOLD Board of Directors

Roberto Rodriguez-Roisin, MDChair

Science Committee

Jrgen Vestbo, MD - Chair

Dissemination/Implementation

Task GroupJean Bourbeau, MD - Chair

GOLD National Leaders - GNL


8/115

United States

United Kingdom

Argentina

Australia

Brazil

AustriaCanada

Chile

Belgium

China

Denmark

Columbia

Croatia

Egypt

Germany

Greece

Ireland

Italy

SyriaHong Kong ROC

Japan

Iceland

India

Korea

KyrgyzstanUruguay

Moldova

Nepal

Macedonia

Malta

Netherlands

New Zealand

Poland

Norway

Portugal

Georgia

Romania

Russia

SingaporeSlovakia

Slovenia Saudi Arabia

South Africa

Spain

Sweden

Thailand

Switzerland

Ukraine

United Arab Emirates

Taiwan ROC

Venezuela

Vietnam

Peru

Yugoslavia

Albania

Bangladesh

France

Mexico

Turkey CzechRepublic

Pakistan

Israel

GOLD National Leaders

Philippines

Yeman

Kazakhstan

Mongolia


9/115

GOLD Website Address

http://www.goldcopd.org


10/115

lobal Initiative for Chronic

bstructive

ung

isease

GO

L

D Global Initiative for Chronic Obstructive Lung Disease


11/115

GOLD Objectives

Increase awareness of COPD amonghealth professionals, health

authorities, and the general publicImprove diagnosis, management andprevention

Decrease morbidity and mortality

Stimulate research


12/115

Global Strategy for Diagnosis, Management andPrevention of COPD, 2011: Chapters

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage ComorbiditiesREVISED 2011


13/115




Therapeutic Options

Manage Stable COPD




14/115

Global Strategy for Diagnosis, Management and Prevention of COPD

Definition of COPD

COPD, a common preventable and treatabledisease, is characterized by persistent airflowlimitation that is usually progressive andassociated with an enhanced chronicinflammatory response in the airways and thelung to noxious particles or gases.

Exacerbations and comorbidities contribute tothe overall severity in individual patients.


15/115


Mechanisms Underlying

Airflow Limitation in COPD

Small Airways Disease

Airway inflammation Airway fibrosis, luminal plugs Increased airway resistance

Parenchymal Destruction

Loss of alveolar attachments Decrease of elastic recoil

AIRFLOW LIMITATION


16/115


Burden of COPD

COPD is a leading cause of morbidity andmortality worldwide.

The burden of COPD is projected to increasein coming decades due to continuedexposure to COPD risk factors and the aging

of the worlds population.

COPD is associated with significant economicburden.


17/115


Risk Factors for COPD

Lung growth and development

Gender

Age

Respiratory infections

Socioeconomic status

Asthma/Bronchial

hyperreactivityChronic Bronchitis

Genes

Exposure to particles

Tobacco smoke

Occupational dusts, organicand inorganic

Indoor air pollution fromheating and cooking with

biomass in poorly ventilateddwellings

Outdoor air pollution


18/115


Risk Factors for COPD

Genes

Infections

Socio-economic

status

Aging Populations


19/115




Therapeutic Options

Manage Stable COPD




20/115


Diagnosis and Assessment: Key Points

A clinical diagnosis of COPD should beconsidered in any patient who has dyspnea,chronic cough or sputum production, and/or a

history of exposure to risk factors for thedisease.

Spirometry is requiredto make the diagnosis;

the presence of a post-bronchodilator FEV1/FVC< 0.70 confirms the presence of persistentairflow limitation and thus of COPD.


21/115


Diagnosis and Assessment: Key Points

The goals of COPD assessment are to determinethe severity of the disease, including the severity ofairflow limitation, the impact on the patients health

status, and the risk of future events.

Comorbidities occur frequently in COPD patients,and should be actively looked for and treated

appropriately if present.


22/115

SYMPTOMS

chronic cough

shortness of breath

EXPOSURE TO RISKFACTORS

tobaccooccupation

indoor/outdoor pollution

SPIROMETRY: Required to establish

diagnosis


Diagnosis of COPD

sputum

Gl b l S f i i d i f CO


23/115


Assessment of Airflow Limitation:Spirometry

Spirometry should be performed after theadministration of an adequate dose of a short-acting inhaled bronchodilator to minimizevariability.

A post-bronchodilator FEV1/FVC < 0.70 confirmsthe presence of airflow limitation.

Where possible, values should be compared toage-related normal values to avoid overdiagnosisof COPD in the elderly.


24/115

Spirometry: Normal Trace ShowingFEV1 and FVC

1 2 3 4 5 6

1

2

3

4

Volume,

lite

rs

Time, sec

FVC5

1

FEV1 = 4LFVC = 5L

FEV1/FVC = 0.8


25/115

Spirometry: Obstructive Disease

Volume,

lite

rs

Time, seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 1.8L

FVC = 3.2L

FEV1/FVC = 0.56

Normal

Obstructive


26/115

Determine the severity of the disease, itsimpact on the patients health status and therisk of future events (for example

exacerbations)to guide therapy. Consider thefollowing aspects of the disease separately:

current level of patients symptoms

severity of the spirometric abnormality frequency of exacerbations presence of comorbidities.


Assessment of COPD: Goals


27/115


Assessment of COPD

Assess symptoms

Assess degree of airflowlimitation using spirometry

Assess risk of exacerbations

Assess comorbidities


28/115

The characteristic symptoms of COPD are chronic andprogressive dyspnea, cough, and sputum production.

Dyspnea:Progressive, persistent and characteristicallyworse with exercise.

Chronic cough:May be intermittent and may beunproductive.

Chronic sputum production:COPD patients commonlycough up sputum.


Symptoms of COPD


29/115

Assess symptoms

Assess degree of airflow limitation using

spirometry



Use the COPD Assessment Test(CAT)or

mMRCBreathlessnessscale


Assessment of COPD


30/115

COPD Assessment Test (CAT):An 8-itemmeasure of health status impairment in COPD(http://catestonline.org).

Breathlessness Measurement using theModified British Medical Research Council

(mMRC) Questionnaire: relates well to othermeasures of health statusand predicts futuremortality risk.


Assessment of Symptoms


31/115


Modified MRC (mMRC)Questionnaire


32/115

Assess symptoms

Assess degree of airflow limitation

usingspirometryAssess risk of exacerbations


Use spirometry for

gradingseverityaccording to spirometry,

usingfour grades split at 80%, 50%and 30% of predictedvalue


Assessment of COPD



33/115


Classification of Severity of AirflowLimitation in COPD*

In patients with FEV1/FVC < 0.70:

GOLD 1: Mild FEV1> 80% predicted

GOLD 2: Moderate 50% < FEV1< 80% predicted

GOLD 3: Severe 30% < FEV1< 50% predicted

GOLD 4: Very Severe FEV1< 30% predicted

*Based on Post-Bronchodilator FEV1


34/115

Assess symptoms

Assess degree of airflow limitation

using spirometry Assess risk of exacerbations

Assess comorbiditiesUsehistory of exacerbations and spirometry.Twoexacerbations or more within the last year

or an FEV1 < 50 % of predictedvalueare

indicators of highrisk


Assessment of COPD


35/115


Assess Risk of Exacerbations

To assessrisk ofexacerbationsusehistory of

exacerbations and spirometry:

Two or more

exacerbationswithinthe last yearoran FEV1 < 50 % ofpredictedvalueareindicators of

hi hrisk.


36/115


CombinedAssessment of COPD

Assess symptoms

Assess degree of airflow limitation usingspirometry


Combinetheseassessments for the purposeof improving management of COPD


37/115



Risk

(GOLD

ClassificationofA

irflow

Limitation

)

Risk

(Exacerbation

history)

> 2

1

0

(C) (D)

(A) (B)

mMRC 0-1

CAT < 10

4

3

2

1

mMRC>2

CAT >10

Symptoms(mMRC or CAT score))

Gl b l S f d f CO


38/115



(C) (D)

(A) (B)mMRC 0-1

CAT < 10

mMRC>2

CAT >10


If mMRC 0-1 or CAT < 10:

Less Symptoms (A or C)

If mMRC> 2 or CAT >10:

More Symptoms (B or D)

Assess symptoms first

Gl b l St t f Di i M t d P ti f COPD


39/115



Risk

(GOLD

Clas

sificationofAirflo

w

Limitation)

Risk

(E

xacerbationhistory)

> 2

1

0

(C) (D)

(A) (B)mMRC 0-1

CAT < 10

4

3

2

1

mMRC>2

CAT >10


If GOLD 1 or 2 andonly

0 or 1 exacerbations per year:Low Risk (A or B)

If GOLD 3 or 4 ortwo ormore exacerbations per year:

High Risk (C or D)

Assessrisk of exacerbationsnext



40/115



Risk

(GOLD

Clas

sificationofAirflo

w

Limitation)

Risk

(E

xacerbationhistory)

> 2

1

0

(C) (D)

(A) (B)mMRC 0-1

CAT < 10

4

3

2

1

mMRC>2

CAT >10


Patient is now in one offourcategories:

A: Les symptoms, lowrisk

B: More symtoms, lowrisk

C: Less symptoms, highrisk

D: More Symtoms, highrisk

Usecombinedassessment



41/115



Risk

(GOLD

ClassificationofA

irflow

Limitation

)

Risk

(Exacerbation

history)

> 2

1

0

(C) (D)

(A) (B)

mMRC 0-1

CAT < 10

4

3

2

1

mMRC>2

CAT >10


Global Strategy for Diagnosis Management and


42/115

Patient Characteristic SpirometricCla

ssification

Exacerbations

per year

mMRC CAT

ALow Risk

Less SymptomsGOLD 1-2 1 0-1 < 10

B

Low Risk

More Symptoms GOLD 1-2 1 >2 10

CHigh Risk

Less SymptomsGOLD 3-4 >2 0-1 < 10

DHigh Risk

More SymptomsGOLD 3-4 >2 >2

10

Global Strategy for Diagnosis, Management andPrevention of COPD

CombinedAssessment

of COPDWhen assessing risk, choose the highest riskaccording to GOLD grade or exacerbation history


43/115


Assess COPD Comorbidities

COPD patients are at increased risk for:

Cardiovasculardiseases Osteoporosis Respiratoryinfections AnxietyandDepression Diabetes

LungcancerThese comorbid conditions may influence mortality

and hospitalizations and should be looked for

routinely, and treated appropriately.



44/115

Differential Diagnosis:COPD and Asthma

COPD

Onset in mid-life

Symptoms slowlyprogressive

Long smoking history

ASTHMA

Onset early in life (often

childhood) Symptoms vary from day to day

Symptoms worse at night/earlymorning

Allergy, rhinitis, and/or eczemaalso present

Family history of asthma


45/115


Additional Investigations

Chest X-ray:Seldom diagnostic but valuable to excludealternative diagnoses and establish presence of significantcomorbidities.

Lung Volumes and Diffusing Capacity:Help to characterizeseverity, but not essential to patient management.

Oximetry and Arterial Blood Gases:Pulse oximetry can be usedto evaluate a patients oxygen saturation and need for

supplemental oxygen therapy.Alpha-1 Antitrypsin Deficiency Screening:Perform when COPDdevelops in patients of Caucasian descent under 45 years orwith a strong family history of COPD.


46/115

Exercise Testing:Objectively measured exercise impairment,assessed by a reduction in self-paced walking distance (suchas the 6 min walking test) or during incremental exercisetesting in a laboratory, is a powerful indicator of healthstatus impairment and predictor of prognosis.

Composite Scores:Several variables (FEV1, exercisetolerance assessed by walking distance or peak oxygen

consumption, weight loss and reduction in the arterialoxygen tension) identify patients at increased risk formortality.


Additional Investigations

Gl b l S f Di i M d


47/115




Therapeutic Options

Manage Stable COPD




48/115


Therapeutic Options: Key Points

Smoking cessation has the greatest capacity toinfluence the natural history of COPD. Health careproviders should encourage all patients who smoketoquit.

Pharmacotherapy and nicotine replacement reliablyincrease long-term smoking abstinence rates.

All COPD patients benefit from regular physicalactivity and should repeatedly be encouraged toremain active.


49/115

Appropriate pharmacologic therapy can reduce COPDsymptoms, reduce the frequency and severity of

exacerbations, and improve health status andexercise tolerance.

None of the existing medications for COPD has beenshown conclusively to modify the long-term decline

in lung function.

Influenza and pneumococcal vaccination should beoffered depending on local guidelines.


Therapeutic Options: Key Points



50/115


Therapeutic Options: Smoking Cessation

Counselingdelivered by physicians and otherhealthprofessionals significantlyincreasesquit rates over self-initiatedstrategies. Even a brief (3-minute) period of

counseling to urge a smoker to quitresults in smokingquit rates of 5-10%.

Nicotinereplacementtherapy (nicotinegum, inhaler,nasal spray, transdermal patch, sublingual tablet, orlozenge) as well as pharmacotherapy with varenicline,bupropion, and nortriptylinereliablyincreases long-termsmoking abstinence rates and aresignificantly moreeffectivethan placebo.

Brief Strategies to Help the


51/115

Brief Strategies to Help thePatient Willing to Quit Smoking

ASKSystematically identify all

tobacco users at every visit

ADVISEStrongly urge all tobaccousers to quit

ASSESSDetermine willingness to

make a quit attempt

ASSISTAid the patient in quitting

ARRANGESchedule follow-up contact.

Global St ateg fo Diagnosis Management and P e ention of COPD


52/115


Therapeutic Options: Risk Reduction

Encourage comprehensive tobacco-control policies with clear,consistent, and repeated nonsmoking messages.

Emphasize primary prevention, best achieved by elimination or

reduction ofexposures in the workplace. Secondaryprevention, achieved through surveillance and early detection,is also important.

Reduce or avoid indoor air pollution from biomass fuel, burned

for cooking and heating in poorly ventilated dwellings.

Advise patients to monitor public announcements ofair qualityand, depending on the severity of their disease, avoid vigorousexercise outdoors or stay indoors during pollution episodes.



53/115


Therapeutic Options: COPD Medications

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



54/115

Bronchodilator medications are central to the

symptomatic management of COPD.

Bronchodilators are prescribed on an as-needed or on a

regular basis to prevent or reduce symptoms.

The principal bronchodilator treatments are beta2-agonists, anticholinergics, theophylline or combinationtherapy.

The choice of treatment depends on the availability of

medications and each patients individual response

in terms of symptom relief and side effects..


Therapeutic Options: Bronchodilators



55/115

Long-acting inhaled bronchodilators are

convenient and more effective for symptom reliefthan short-acting bronchodilators.

Long-acting inhaled bronchodilators reduceexacerbations and related hospitalizationsandimprove symptoms and healthstatus.

Combining bronchodilators of differentpharmacological classes may improve efficacy anddecrease the risk of side effects compared toincreasing the dose of a single bronchodilator.


Therapeutic Options: Bronchodilators



56/115

Regular treatment with inhaled corticosteroids (ICS)

improves symptoms, lung function and quality of lifeand reduces frequency of exacerbations for COPD

patients with an FEV1


57/115

An inhaled corticosteroid combined with a long-acting

beta2-agonist is more effective than the individualcomponents in improving lung function and health

status and reducing exacerbations in moderate to verysevere COPD.

Combination therapy is associated with an increased riskof pneumonia.

Addition of a long-acting beta2-agonist/inhaledglucorticosteroid combination to an anticholinergic(tiotropium) appears to provide additional benefits.

Therapeutic Options: CombinationTherapy



58/115

Chronic treatment with systemic

corticosteroids should be avoided because ofan unfavorable benefit-to-risk ratio.

Therapeutic Options: SystemicCorticosteroids


Th ti O ti


59/115

In patients with severe and very severeCOPD (GOLD 3 and 4) and a history ofexacerbations and chronic bronchitis, thephospodiesterase-4 inhibitor (PDE-4),roflumilast, reduces exacerbations treated

with oral glucocorticosteroids.

Therapeutic Options:Phosphodiesterase-4 Inhibitors



60/115

G oba S a egy o ag os s, a age e a d e e o o CO

Therapeutic Options: Theophylline

Theophylline is less effective and less well tolerated thaninhaled long-acting bronchodilators and is notrecommended if those drugs are available and affordable.

There is evidence for a modest bronchodilator effect andsome symptomatic benefit compared with placebo in stableCOPD. Addition of theophylline to salmeterolproduces agreater increase in FEV1 and breathlessness than

salmeterolalone.

Low dose theophylline reduces exacerbations but does notimprove post-bronchodilator lung function.


Therapeutic Options: Other


61/115

Influenza vaccinescan reduce serious illness.Pneumococcal polysaccharide vaccine is recommendedfor COPD patients 65 years and older and for COPDpatients younger than age 65 with an FEV1< 40%predicted.

The use ofantibiotics, other than for treating infectious

exacerbations of COPD and other bacterial infections, iscurrently not indicated.

Therapeutic Options: OtherPharmacologic Treatments


Therapeutic Options: Other


62/115

Alpha-1 antitrypsin augmentation therapy:notrecommended for patients with COPD that is unrelatedto the genetic deficiency.

Mucolytics:Patients with viscous sputum may benefitfrom mucolytics; overall benefits are very small.

Antitussives: Not recommended.

Vasodilators:Nitric oxide is contraindicated in stableCOPD. The use of endothelium-modulating agents forthe treatment of pulmonary hypertension associated

with COPD is not recommended.

Therapeutic Options: OtherPharmacologic Treatments

Global Strategy for Diagnosis Management and Prevention of COPD


63/115

All COPD patients benefit from exercise trainingprogramswith improvements in exercise toleranceand symptoms of dyspnea and fatigue.

Although an effective pulmonary rehabilitationprogram is 6 weeks, the longer the programcontinues, the more effective the results.

If exercise training is maintained at home thepatient's health status remains above pre-rehabilitation levels.


Therapeutic Options: Rehabilitation



64/115

Oxygen Therapy: The long-term administration ofoxygen (> 15 hours per day) to patients with chronicrespiratory failure has been shown to increase

survival in patients with severe, resting hypoxemia.

Ventilatory Support:Combination of noninvasiveventilation (NIV) with long-term oxygen therapy may

be of some use in a selected subset of patients,particularly in those with pronounced daytimehypercapnia.


Therapeutic Options: Other Treatments


Th ti O ti S i l


65/115

Lung volume reduction surgery (LVRS)is moreefficacious than medical therapy among patientswith upper-lobe predominant emphysema and low

exercise capacity.

LVRSis costly relative to health-care programs notincluding surgery.

In appropriately selected patients with very severeCOPD, lung transplantationhas been shown toimprove quality of life and functional capacity.

Therapeutic Options: SurgicalTreatments

Global Strategy for Diagnosis Management and


66/115

Global Strategy for Diagnosis, Management andPrevention of COPD, 2011: Major Chapters



Therapeutic Options

Manage Stable COPD





67/115

Identification and reduction of exposure to risk factorsare important steps in prevention and treatment.

Individualized assessment of symptoms, airflow

limitation, and future risk of exacerbations should beincorporated into the management strategy.

All COPD patients benefit from rehabilitation andmaintenance of physical activity.

Pharmacologic therapy is used to reduce symptoms,reduce frequency and severity of exacerbations, andimprove health status and exercise tolerance.

Manage Stable COPD: Key Points



68/115

Long-acting formulations of beta2-agonists

and anticholinergicsare preferred over short-acting formulations. Based on efficacy and

side effects, inhaled bronchodilators arepreferred over oral bronchodilators.

Long-term treatment with inhaled

corticosteroids added to long-actingbronchodilators is recommended for patientswith high risk of exacerbations.




69/115

Long-term monotherapy with oral or inhaled

corticosteroids is not recommended inCOPD.

The phospodiesterase-4 inhibitor roflumilastmay be useful to reduce exacerbations forpatients with FEV1 < 50% of predicted,

chronic bronchitis, and frequentexacerbations.



bl l f h


70/115

Relieve symptoms

Improve exercise tolerance

Improve health status

Prevent disease progression

Prevent and treat exacerbations

Reduce mortality

Reduce

symptoms

Reducerisk

Manage Stable COPD: Goals of Therapy



71/115

Avoidance of risk factors

- smoking cessation

- reduction of indoor pollution

- reduction of occupational exposureInfluenza vaccination

Manage Stable COPD: All COPD Patients


S bl CO h l i


72/115

Manage Stable COPD: Non-pharmacologic

Patient Essential Recommended Depending on local

guidelines

A

Smoking cessation

(canincludepharmacologi

ctreatment)

Physicalactivity

Flu vaccination

Pneumococcal

vaccination

B, C, D

Smoking cessation(canincludepharmacologi

ctreatment)

Pulmonary rehabilitation

Physicalactivity

Flu vaccination

Pneumococcal

vaccination


Manage Stable COPD: PharmacologicTherapy


73/115

Manage Stable COPD: PharmacologicTherapy(Medications in each box are mentioned in alphabetical order, and

therefore not necessarily in order of preference.)

Patient First choice Second choice AlternativeChoices

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA

LAMA and LABASABA and/orSAMA

Theophylline

C

ICS +LABA

or

LAMA LAMA and LABA

PDE4-inh.

SABA and/orSAMATheophylline

D

ICS + LABA

or

LAMA

ICS andLAMA or

ICS + LABA and LAMA or

ICS+LABA and PDE4-inh.or

LAMA and LABA or

LAMA and PDE4-inh.

Carbocysteine

SABA and/orSAMA

Theophylline




74/115

Exa

cerbationsperyear

> 2

1

0

mMRC 0-1

CAT < 10

GOLD 4

mMRC>2

CAT >10

GOLD 3

GOLD 2

GOLD 1

SAMAprn

orSABA prn

LABA

orLAMA

ICS + LABA

or

LAMA

a age Stab e CO a aco og c e apy

FIRST CHOICE

A B

DC

ICS + LABA

or

LAMA




75/115

> 2

1

0

mMRC 0-1

CAT < 10

GOLD 4

mMRC> 2

CAT > 10

GOLD 3

GOLD 2

GOLD 1

LAMA or

LABA or

SABA and SAMA

LAMA and LABA ICS and LAMA orICS + LABA and LAMA or

ICS + LABA and PDE4-inh or

LAMA and LABA orLAMA and PDE4-inh.

LAMA and LABA

g g py

SECOND CHOICE

A

DC

B

Exa

cerbationsperyear




76/115

> 2

1

0

mMRC 0-1

CAT < 10

GOLD 4

mMRC> 2

CAT >10

GOLD 3

GOLD 2

GOLD 1

Theophylline

PDE4-inh.SABA and/or SAMA

Theophylline

CarbocysteineSABA and/or SAMA

Theophylline

SABA and/or SAMATheophylline

g g py

ALTERNATIVE CHOICES

A

DC

B

Exa

cerbationsperyear

Global Strategy for Diagnosis, Management and


77/115

G oba St ategy o ag os s, a age e t a dPrevention of COPD, 2011: Chapters



Therapeutic Options

Manage Stable COPD





78/115

An exacerbation of COPD is:

an acute event characterized by a

worsening of the patients respiratorysymptoms that is beyond normal day-to-day variations and leads to a

change in medication.

ManageExacerbations



79/115

The most common causes of COPD exacerbationsare viral upper respiratory tract infections andinfection of the tracheobronchial tree.

Diagnosis relies exclusively on the clinicalpresentation of the patient complaining of an acutechange of symptoms that is beyond normal day-to-day variation.

The goal of treatment is to minimize the impact ofthe current exacerbation and to prevent thedevelopment of subsequent exacerbations.

Manage Exacerbations: Key Points


b


80/115

Short-acting inhaled beta2-agonists with or withoutshort-acting anticholinergics are usually thepreferred bronchodilators for treatment of an

exacerbation. Systemic corticosteroids and antibiotics can shorten

recovery time, improve lung function (FEV1) andarterial hypoxemia (PaO2),and reduce the risk ofearly relapse, treatment failure, and length ofhospital stay.

COPD exacerbations can often be prevented.

ManageExacerbations: Key Points

Consequences Of COPD Exacerbations


81/115

Impact onsymptoms

and lung

function

Negativeimpact on

quality of life

Consequences Of COPD Exacerbations

Increased

economic

costs

Accelerated

lung function

decline

Increased

Mortality

EXACERBATIONS



82/115

Arterialblood gas measurements (in hospital): PaO2< 8.0 kPawith or without PaCO2> 6.7 kPa whenbreathingroom airindicatesrespiratoryfailure.

Chestradiographs:useful to exclude alternative diagnoses.

ECG:mayaid in the diagnosis of coexistingcardiac problems.

Whole bloodcount: identifypolycythemia, anemiaor bleeding.

Purulentsputumduring an exacerbation: indication to

beginempiricalantibiotictreatment.

Biochemicaltests:detectelectrolytedisturbances, diabetes, andpoornutrition.

Spirometric tests:not recommended during an exacerbation.

Manage Exacerbations: Assessments


b O


83/115

Oxygen:titrate to improve the patients hypoxemia with atarget saturation of 88-92%.

Bronchodilators:Short-acting inhaled beta2-agonists with or

without short-acting anticholinergics are preferred.

Systemic Corticosteroids:Shorten recovery time, improve lung

function (FEV1) and arterial hypoxemia (PaO2), and reduce

the risk of early relapse, treatment failure, and length of

hospital stay. A dose of 30-40 mg prednisolone per day for

10-14 days is recommended.

ManageExacerbations:Treatment Options


M E b i T O i


84/115

Antibioticsshould be given to patients with:

Three cardinal symptoms: increased

dyspnea, increased sputum volume, andincreased sputum purulence.

Who require mechanical ventilation.

ManageExacerbations:Treatment Options


ManageExacerbations:


85/115

Noninvasive ventilation (NIV):

Improves respiratory acidosis, reduces

respiratory rate, severity of dyspnea,complications and length of hospital stay.

decreases mortality and needs forintubation.

GOLD Revision 2011

gTreatmentOptions


ManageExacerbations:Indications for


86/115

Marked increase in intensity of symptoms

Severe underlying COPD

Onset of new physical signs

Failure of an exacerbation to respond to initialmedical management

Presence of serious comorbidities

Frequent exacerbations Older age

Insufficient home support

ManageExacerbations:Indications for

Hospital Admission



87/115

Prevention of COPD, 2011: Major Chapters



Therapeutic Options

Manage Stable COPD




M C biditi


88/115

COPD oftencoexists with otherdiseases

(comorbidities) thatmay have a

significantimpact on prognosis. In general,

presence of comorbidities should not alter

COPD treatment and comorbidities should be

treated as if the patient did not have COPD.

ManageComorbidities


M C biditi


89/115

Cardiovascular disease(including ischemic

heart disease, heart failure, atrial fibrillation,

and hypertension) is a major comorbidity inCOPD and probably both the most frequent

and most important disease coexisting with

COPD. Cardioselective beta-blockers are notcontraindicated in COPD.

ManageComorbidities


M C biditi


90/115

Osteoporosisand anxiety/depression:often under-diagnosed and associated with poor health status andprognosis.

Lung cancer: frequent in patients with COPD; the mostfrequent cause of death in patients with mild COPD.

Serious infections: respiratory infectionsare especially

frequent.Metabolic syndromeand manifest diabetes: morefrequent in COPD and the latter is likely to impact on

prognosis.

ManageComorbidities



91/115

Prevention of COPD, 2011: Chapters



Therapeutic Options

Manage Stable COPD



Global Strategy for Diagnosis, Management


92/115

Prevention of COPD is to a large extent possibleand should have high priority

Spirometry is requiredto make the diagnosis ofCOPD; the presence of a post-bronchodilatorFEV1/FVC < 0.70 confirms the presence ofpersistent airflow limitation and thus of COPD

The beneficial effects of pulmonary rehabilitationand physical activity cannot be overstated

gy g , gand Prevention of COPD, 2011: Summary



93/115

Assessment of COPD requiresassessment of symptoms, degree of

airflow limitation, risk ofexacerbations, and comorbidities

Combined assessment of symptoms

and risk of exacerbations is the basisfor non-pharmacologic andpharmacologic management of COPD




94/115

Treat COPDexacerbationstominimizetheirimpactan

d topreventthedevelopment ofsubsequentexacerbations

Look for comorbidities and if present

treat to the same extent as if thepatient did not have COPD


WORLD COPD DAY


95/115

WORLD COPD DAY

November 14, 2012

Raising COPD Awareness Worldwide

United States A stralia

Brazil

C dCroatia

Germany

Ireland

Slovenia Saudi Arabia

Yugoslavia

Bangladesh


96/115

United States

United Kingdom

Argentina

AustraliaAustria

Canada

Chile

Belgium

China

Denmark

Columbia

Croatia

Egypt

Greece

Italy

SyriaHong Kong ROC

Japan

Iceland

India

Korea

KyrgyzstanUruguay

Moldova

Nepal

Macedonia

Malta

Netherlands

New Zealand

Poland

Norway

Portugal

Georgia

Romania

Russia

SingaporeSlovakia

South Africa

Spain

Sweden

Thailand

Switzerland

Ukraine

United Arab Emirates

Taiwan ROC

Venezuela

Vietnam

Peru

Yugoslavia

Albania

France

Mexico

Turkey CzechRepublic

Pakistan

Israel

GOLD National Leaders

PhilippinesYeman

Kazakhstan

Mongolia



97/115


http://www.goldcopd.org


98/115

ADDITIONAL SLIDES PREPARED BYPROFESSOR PETER J. BARNES, MD

NATIONAL HEART AND LUNG INSTITUTE

LONDON, ENGLAND


99/115


100/115


101/115


102/115


103/115


104/115


105/115


106/115


107/115


108/115


109/115


110/115


111/115


112/115


113/115


114/115


115/115

Documents

how to make money by selling simple items made in self-suficcient home industries