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COPD diagnosis, management and prevention

* Recommendations by the GOLD Committees for use of any medication are based on the best evidence available from the published literature and not on labelling directives from government regulators

Diagnosis and initial assessment

  • COPD should be considered in any patient who has dyspnoea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease
  • Spirometry is required to make the diagnosis; the presence of a post-bronchodilator forced expiratory volume in the first second [FEV1]/forced vital capacity [FVC]<0.70 confirms the presence of persistent airflow limitation
  • The goals of COPD assessment are to determine the level of airflow limitation, the impact of disease on the patient's health status, and the risk of future events (such as exacerbations, hospital admissions, or death), in order to guide therapy
  • Concomitant chronic diseases occur frequently in COPD patients, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalisations independently
  • Differential diagnosis of COPD:
    • COPD
    • asthma
    • congestive heart failure
    • bronchiectasis
    • tuberculosis
    • obiterative bronchiolitis
    • diffuse bronchiolitis

Key indicators for considering a diagnosis of COPD

  • Consider COPD, and perform spirometry, if any of these indicators are present in an individual over age 40. These indicators are not diagnostic themselves, but the presence of multiple key indicators increases the probability of a diagnosis of COPD. Spirometry is required to establish a diagnosis of COPD
  • Dyspnoea that is:
    • progressive over time
    • characteristically worse with exercise
    • persistent
  • Chronic cough:
    • may be intermittent and may be unproductive
    • recurrent wheeze
  • Chronic sputum production—any pattern of chronic sputum production may indicate COPD
  • Recurrent lower respiratory tract infections
  • History of risk factors
    • host factors (such as genetic factors, congenital/developmental abnormalities)
    • tobacco smoke (including popular local preparations)
    • smoke from home cooking and heating fuels
    • occupational dusts, vapours, fumes, gases, and other chemicals
  • Family history of COPD and/or childhood factors—for example low birthweight, childhood respiratory infection

Assessment

Classification of airflow limitation severity in COPD (based on post-bronchodilator FEV1)

  • In patients with FEV1/FVC:
    • 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

Revised combined COPD assessment

The refined ABCD assessment tool

  • In the refined assessment scheme (see figure above), patients should undergo spirometry to determine the severity of airflow limitation (i.e., spirometric grade). They should also undergo assessment of either dyspnea using modified Medical Research Council (mMRC), or symptoms using COPD assessment test (CAT). Finally, their history of exacerbations (including prior hospitalisations) should be recorded
  • The number provides information regarding severity of airflow limitation (spirometric grade 1 to 4) while the letter (groups A to D) provides information regarding symptom burden and risk of exacerbation which can be used to guide therapy (see treatment algortihm below)
  • Example: Consider two patients—both patients with FEV1 <30% of predicted, CAT scores of 18 and one with no exacerbations in the past year and the other with three exacerbations in the past year. Both would have been labelled GOLD D in the prior classification scheme. However, with the new proposed scheme, the subject with three exacerbations in the past year would be labelled GOLD grade 4, group D.The other patient, who has had no exacerbations, would be classified as GOLD grade 4, group B

Evidence supporting prevention and maintenance therapy

  • Smoking cessation is key. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates
  • The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at present
  • Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance
  • Each pharmacologic treatment regimen should be individualised and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and cost, and the patient’s response, preference and ability to use various drug delivery devices
  • Inhaler technique needs to be assessed regularly
  • Influenza vaccination decreases the incidence of lower respiratory tract infections
  • Pneumococcal vaccination decreases lower respiratory tract infections
  • Pulmonary rehabilitation improves symptoms, quality of life, and physical and emotional participation in everyday activities
  • In patients with severe resting chronic hypoxemia, long-term oxygen therapy improves survival
  • In patients with stable COPD and resting or exercise-induced moderate desaturation, long-term oxygen treatment should not be prescribed routinely. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen
  • In patients with severe chronic hypercapnia and a history of hospitalisation for acute respiratory failure, long-term non-invasive ventilation may decrease mortality and prevent re-hospitalisation
  • In select patients with advanced emphysema refractory to optimised medical care, surgical or bronchoscopic interventional treatments may be beneficial
  • Palliative approaches are effective in controlling symptoms in advanced COPD

Management of stable COPD

  • The management strategy for stable COPD should be predominantly based on the individualised assessment of symptoms and future risk of exacerbations
  • All individuals who smoke should be strongly encouraged and supported to quit
  • The main treatment goals are reduction of symptoms and future risk of exacerbations
  • Management strategies are not limited to pharmacologic treatments, and should be complemented by appropriate non-pharmacologic interventions

Treatment of stable COPD

Pharmacologic treatment

Pharmacologic treatment algorithms by GOLD grade (highlighted boxes and arrows indicate preferred treatment pathways)
  • Group A:
    • all Group A patients should be offered bronchodilator treatment based on its effect on breathlessness. This can be either a short- or a long-acting bronchodilator
    • this should be continued if symptomatic benefit is documented
  • Group B:
    • initial therapy should consist of a long-acting bronchodilator. Long-acting inhaled bronchodilators are superior to short-acting bronchodilators taken as needed i.e., p.r.n. and are therefore recommended
    • there is no evidence to recommend one class of long-acting bronchodilators over another for initial relief of symptoms in this group of patients. In the individual patient, the choice should depend on the patient's perception of symptom relief
    • for patients with persistent breathlessness on monotherapy the use of two bronchodilators is recommended
    • for patients with severe breathlessness initial therapy with two bronchodilators may be considered
    • if the addition of a second bronchodilator does not improve symptoms, we suggest the treatment could be stepped down again to a single bronchodilator
  • Group B patients are likely to have comorbidities that may add to their symptomatology and impact their prognosis, and these possibilities should be investigated
  • Group C:
    • initial therapy should consist of a single long-acting bronchodilator. In two head-to-head comparisons the tested long-acting muscarinic antagonist (LAMA) was superior to the long-acting beta2 -agonist (LABA) regarding exacerbation prevention, therefore we recommend starting therapy with a LAMA in this group
    • patients with persistent exacerbations may benefit from adding a second long-acting bronchodilator (LABA/LAMA) or using a combination of a LABA and an inhaled corticosteroid (LABA/ICS). As ICS increases the risk for developing pneumonia in some patients, our primary choice is LABA/LAMA
  • Group D:
    • we recommend starting therapy with a LABA/LAMA combination because:
      • in studies with patient reported outcomes as the primary endpoint LABA/LAMA combinations showed superior results compared to the single substances. If a single bronchodilator is chosen as initial treatment, a LAMA is preferred for exacerbation prevention based on comparison to LABAs
    • a LABA/LAMA combination was superior to a LABA/ICS combination in preventing exacerbations and other patient reported outcomes in Group D patients
    • Group D patients are at higher risk of developing pneumonia when receiving treatment with ICS
  • In some patients initial therapy with LABA/ICS may be the first choice. These patients may have a history and/or findings suggestive of asthma-COPD overlap. High blood eosinophil counts may also be considered as a parameter to support the use of ICS, although this is still under debate
  • In patients who develop further exacerbations on LABA/LAMA therapy we suggest two alternative pathways:
    • escalation to LABA/LAMA/ICS. Studies are underway comparing the effects of LABA/LAMA versus LABA/LAMA/ICS for exacerbation prevention
    • switch to LABA/ICS. However, there is no evidence that switching from LABA/LAMA to LABA/ICS results in better exacerbation prevention. If LABA/ICS therapy does not positively impact exacerbations/symptoms, a LAMA can be added
  • If patients treated with LABA/LAMA/ICS still have exacerbations the following options may be considered:
    • add roflumilast. This may be considered in patients with an FEV1 <50% predicted and chronic bronchitis, particularly if they have experienced at least one hospitalisation for an exacerbation in the previous year
    • add a macrolide. The best available evidence exists for the use of azithromycin. Consideration to the development of resistant organisms should be factored into decision making
    • stopping ICS. A reported lack of efficacy, an elevated risk of adverse effects (including pneumonia) and evidence showing no significant harm from withdrawal supports this recommendation

Non-pharmacologic treatment

  • Based on GOLD groups, personalised design could include:
    • groups A, B, C and D—addressing behavioral risk factors, including smoking cessation, maintaining or increasing physical activity, and ensuring adequate sleep and a healthy diet
    • groups B and D—learning to self-manage breathlessness, energy conservation techniques, and stress management strategies
    • groups C and D—avoiding aggravating factors, monitoring and managing worsening symptoms, having a written action plan and maintaining regular contact/communication with a healthcare professional
    • group D—discussing with their healthcare providers palliative strategies and advance care directives

Monitoring and follow-up

  • Routine follow-up of COPD patients is essential. Lung function may worsen over time, even with the best available care. Symptoms, exacerbations and objective measures of airflow limitation should be monitored to determine when to modify management and to identify any complications and/or comorbidities that may develop

Pharmacotherapy and other medical treatment

  • In order to adjust therapy appropriately as the disease progresses, each follow-up visit should include a discussion of the current therapeutic regimen. Monitoring should focus on:
    • dosages of prescribed medications
    • adherence to the regimen
    • inhaler technique
    • effectiveness of the current regimen
    • side-effects
  • Treatment modifications should be recommended (see algorithm above)

Management of exacerbations

  • An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy
  • Exacerbations of COPD can be precipitated by several factors. The most common causes are respiratory tract infections
  • The goal for treatment of COPD exacerbations is to minimise the negative impact of the current exacerbation and to prevent subsequent events
  • Short-acting inhaled beta2 -agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation
  • Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge
  • Systemic corticosteroids can improve lung function (FEV1), oxygenation and shorten recovery time and hospitalisation duration. Duration of therapy should not be more than 5–7 days
  • Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalisation duration. Duration of therapy should be 5–7 days
  • Methylxanthines are not recommended due to increased side-effect profiles
  • Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindication because it improves gas exchange, reduces work of breathing and the need for intubation, decreases hospitalisation duration and improves survival
  • Following an exacerbation, appropriate measures for exacerbation prevention should be initiated

COPD and comorbidities

  • COPD often coexists with other diseases (comorbidities) that may have a significant impact on disease course
  • In general, the presence of comorbidities should not alter COPD treatment and comorbidities should be treated per usual standards regardless of the presence of COPD
  • Lung cancer is frequently seen in patients with COPD and is a main cause of death
  • Cardiovascular diseases are common and important comorbidities in COPD
  • Osteoporosis and depression/anxiety are frequent, important comorbidities in COPD, are often under diagnosed, and are associated with poor health status and prognosis
  • Gastroesophageal reflux is associated with an increased risk of exacerbations and poorer health status
  • When COPD is part of a multimorbidity care plan, attention should be directed to ensure simplicity of treatment and to minimise polypharmacy

further information and downloads are available from…
www.goldcopd.org

Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.
First included: February 2016.