GOLD COPD Guidelines Flashcards

Levels of Evidence (GOLD)

• A: High-quality RCTs with consistent findings.
  • Requires \ge 2 clinical trials or a single high-quality RCT with substantial subjects.
• B: RCTs with limitations, subgroup analyses, or meta-analyses.
  • Few RCTs exist, or important limitations (methodological flaws, small numbers, short duration).
• C: Outcomes from uncontrolled or non-randomized trials/observational studies.
• D: Panel consensus judgment due to insufficient clinical literature.
  • Based on clinical experience not meeting the above criteria.

FEV1 Trajectories

• Lung function (% of predicted peak) over the life course, showing:
  • Supranormal, Normal, Pseudonormal, Below Normal trajectories.
  • Impact of childhood, puberty, adulthood, and aging.
  • Premature and Accelerated Decline leading to Death.

COPD Etiotypes Taxonomy

• COPD-G: Genetically determined (e.g., Alpha-1 antitrypsin deficiency).
• COPD-D: Due to abnormal lung development (early life events).
• COPD-C: Cigarette smoking (including in utero, passive smoking, vaping, cannabis).
• COPD-P: Environmental (household pollution, ambient air pollution, occupational hazards).
• COPD-I: Due to infections (childhood, tuberculosis, HIV).
• COPD-A: COPD & Asthma (particularly childhood asthma).
• COPD-U: Unknown cause.

Clinical Indicators for COPD Diagnosis

• Dyspnea: progressive, worse with exercise, persistent.
• Recurrent wheeze.
• Chronic cough: may be intermittent, non-productive.
• Recurrent lower respiratory tract infections.
• History of risk factors: tobacco smoke, home cooking/heating fuels, occupational exposures, host factors.

Other Causes of Chronic Cough

• Intrathoracic: Asthma, Lung Cancer, Tuberculosis, Bronchiectasis, Left Heart Failure, Interstitial Lung Disease, Cystic Fibrosis.
• Extrathoracic: Chronic Allergic Rhinitis, Post Nasal Drip Syndrome (PNDS)/Upper Airway Cough Syndrome (UACS), Gastroesophageal Reflux, Medication (e.g., ACE Inhibitors).

Differential Diagnosis of COPD

• COPD: Slowly progressive symptoms, history of smoking/risk factors.
• Asthma: Variable airflow obstruction, symptoms vary, worse at night/early morning, allergy/rhinitis/eczema, often in children, family history.
• Congestive Heart Failure: Chest X-ray shows dilated heart, pulmonary edema, PFTs with volume restriction.
• Bronchiectasis: Large volumes of purulent sputum, bacterial infection, bronchial dilation on Chest X-ray/HRCT.
• Tuberculosis: Lung infiltrate on Chest X-ray, microbiological confirmation.
• Obliterative bronchiolitis: Post-transplant, hypodense areas on HRCT.
• Diffuse panbronchiolitis: Asian descent, male, non-smokers, chronic sinusitis, centrilobular nodular opacities on Chest X-ray/HRCT.

Spirometry Considerations

• Preparation: Trained supervisor, maximal patient effort, follow recommendations.
• Performance: Smooth expiratory curve, pause < 1 second, volume plateau, \ge 3 satisfactory curves within 5% or 150 mL.
• Bronchodilation: 400 mcg short-acting beta2-agonist or 160 mcg short-acting anticholinergic.
  • Measure FEV1 10-15 minutes after beta2-agonist or 30-45 minutes after anticholinergic.
• Evaluation: Compare with reference values, post-bronchodilator FEV1/FVC < 0.7 confirms airflow obstruction.

Spirometry Traces

• Normal Trace: FEV1/FVC = 0.8
• Airflow Obstruction: FEV1/FVC = 0.56

Pre- and Post-Bronchodilator Spirometry

• If Pre-BD FEV1/FVC \ge 0.7 , not COPD.
• If Pre-BD FEV1/FVC < 0.7 , measure Post-BD FEV1/FVC.
  • If Post-BD FEV1/FVC \ge 0.7 , flow response needs follow-up.
  • If Post-BD FEV1/FVC < 0.7 , COPD confirmed.

Role of Spirometry in COPD

• Diagnosis.
• Assessment of severity of airflow obstruction.
• Follow-up assessment.
• Therapeutic decisions (pharmacological & non-pharmacological).
• Identification of rapid decline.

GOLD Grades of Airflow Obstruction

• GOLD 1 (Mild): FEV1 \ge 80 % predicted.
• GOLD 2 (Moderate): 50% \le FEV1 < 80 % predicted.
• GOLD 3 (Severe): 30% \le FEV1 < 50 % predicted.
• GOLD 4 (Very Severe): FEV1 < 30 % predicted.

Modified MRC Dyspnea Scale

• Grade 0: Breathless with strenuous exercise.
• Grade 1: Short of breath when hurrying or walking up a slight hill.
• Grade 2: Walks slower than others or stops for breath on the level.
• Grade 3: Stops for breath after walking about 100 meters or a few minutes on the level.
• Grade 4: Too breathless to leave the house, breathless when dressing.

GOLD ABE Assessment Tool

• Grade (FEV1 % predicted): GOLD 1 (\ge80), GOLD 2 (50-79), GOLD 3 (30-49), GOLD 4 (<30)
• Exacerbation History (Assess Symptoms/Risk):
  • E: > 2 moderate or > 1 leading to hospitalization
  • A: mMRC 0-1 and CAT < 10, B: MMRC \ge 2 and CAT \ge 10

CT Scan Use in COPD

• Differential Diagnosis: Excessive cough with sputum, concern for bronchiectasis.
• Lung Volume Reduction: Endobronchial valve therapy, lung volume reduction surgery.
• Lung Cancer Screening: Annual low-dose CT for smokers.

Goals for COPD Treatment

• Reduce Symptoms & Reduce Risk.
• Relieve Symptoms, Improve Exercise Tolerance, Improve Health Status.
• Prevent Disease Progression, Prevent & Treat Exacerbations, Reduce Mortality.

Management of COPD

• Initial Assessment: Symptoms, risk factors, spirometry, exacerbation history.
• Review: Symptoms, diagnosis, risk factors, spirometry, smoking status.
• Adjust: Smoking Status, blood eosinophil count, comorbidities.

Identify & Reduce Risk Factor Exposure

• Smoking cessation (Evidence A).
• Efficient ventilation, non-polluting cooking stoves (Evidence B).
• Avoid continued exposure to irritants (Evidence D).

Brief Strategies to Help Patients Quit Smoking

• Ask: Systematically identify tobacco users.
• Advise: Urge all tobacco users to quit.
• Assess: Determine willingness to quit.
• Assist: Aid in quitting.
• Arrange: Schedule follow-up.

Treating Tobacco Use

• Dependence is a chronic condition requiring repeated treatment.
• Effective treatments exist, offer to all users.
• Identify, document, and treat every user at every visit.
• Brief counseling is effective.
• Dose-response relation between intensity and effectiveness.
• Effective counseling types: practical, social support.
• First-line pharmacotherapies are effective.

Vaccination for Stable COPD

• Yearly influenza (Evidence B).
• SARS-CoV-2 (COVID-19) vaccination (Evidence B).
• Either PCV21 or PCV20 (Evidence B).
• RSV vaccination for individuals aged \ge 60 years and/or with chronic heart or lung disease, as recommended by the CDC (Evidence A).
• Tdap vaccination (Evidence B).
• Zoster vaccine for people aged > 50 years (Evidence B).

Initial Pharmacological Treatment

• Group A: A bronchodilator.
• Group B: LABA + LAMA.
• Group E: LABA + LAMA; consider LABA + LAMA + ICS if blood eos \ge 300

Pharmacological Treatment Management Cycle

• Review: Symptoms (dyspnea, exacerbations), assess inhaler technique.
• Adjust: Escalate, switch inhaler, de-escalate according to the most recent guidelines.

Follow-up Pharmacological Treatment

• Dyspnea: LABA or LAMA \rightarrow LABA + LAMA \rightarrow switch inhaler, non-pharmacological, ensifentrine, investigate other causes.
• Exacerbations:
  • If blood eos <300 : LABA+LAMA \rightarrow LABA+LAMA+ICS if blood eos \ge 300
  • LABA + LAMA + ICS \rightarrow roflumilast (FEV1 < 50 % & chronic bronchitis), azithromycin (former smokers), dupilumab (chronic bronchitis.)

Key Points for Drug Inhalation

• Importance of education and training in inhaler technique.
• Choice of inhaler tailored to patient ability and preference.
• Provide instructions and re-check technique at each visit.
• Assess technique before concluding therapy is insufficient.

Basic Principles for Inhalation Device Choice

• Drug availability, patient beliefs, satisfaction, preferences.
• Minimize device types per patient, avoid switching without justification.
• Shared decision-making, patient cognition, dexterity, strength.
• Assess ability to perform correct inhalation maneuver.

Non-Pharmacological Management of COPD

• Essential: Influenza, COVID-19 vaccinations, Smoking cessation, Pneumococcal vaccination, Physical activity.
• Recommended: Pulmonary rehabilitation, Pertussis vaccination, Shingles vaccination, RSV vaccination.

Follow-up of Non-Pharmacological Treatment

• Maintain appropriate initial treatment, offer vaccinations, self-management education.
• If not, consider treatable traits: breathlessness (self-management, pulmonary rehabilitation) and exacerbations (self-management, pulmonary rehabilitation).
• Advanced COPD: Consider end-of-life and palliative care.

Oxygen Therapy and Ventilatory Support

• Long-term oxygen increases survival in severe chronic hypoxemia (Evidence A).
• NPPV may improve hospitalization-free survival, especially in hypercapnia (PaCO2 > 53 mmHg) (Evidence B).
• Long-term noninvasive ventilation may be considered after hospitalization for acute respiratory failure (Evidence B).

Prescription of Supplemental Oxygen

• Hypoxemia: PaO2 \le 55 mmHg or SaO2 < 88 %.
  • Or PaO2 > 55 but < 60 mmHg with right heart failure or erythrocytosis.
• Titrate oxygen to keep SaO2 \ge 90 %.
• Recheck in 60-90 days.

Palliative Care in COPD

• Clinicians should be aware of palliative approaches for symptom control (Evidence D).
• End-of-life discussions about resuscitation, advance directives (Evidence D).
• Opiates, NMES, oxygen, and fans can relieve breathlessness (Evidence C).
• Nutritional supplementation for malnourished patients (Evidence B).
• Fatigue can be improved (Evidence B).

Evidence Supporting Mortality Reduction

• Pharmacotherapy: LABA+LAMA+ICS (HR 0.72 IMPACT Trial) and (ETHOS: HR 0.51).
• Smoking cessation (HR 1.18 usual care vs intervention).
• Pulmonary rehabilitation (RR 0.28 old trials, RR 0.68 new trials).
• Long-term oxygen therapy (50% reduction).
• Noninvasive ventilation (HR 0.24 patients with marked hypercapnia).
• Lung volume reduction surgery (RR 0.47 for death).

Maintenance Medications in COPD

• Lists various generic drug names, their inhaler types, delivery methods, and durations of action for:
  • Beta2-Agonists (Short-acting and Long-acting).
  • Anticholinergics (Short-acting and Long-acting).
  • Combination Short-Acting Beta₂-Agonist Plus Anticholinergic.
  • Combination Long-Acting Beta₂-Agonist Plus Anticholinergic.
  • Methylxanthines.
  • Combination of Long-Acting Beta₂-Agonist Plus Corticosteroid.
  • Triple Combination.
  • Phosphodiesterase Inhibitors, Mucolytic Agents, Biologics

Bronchodilators in Stable COPD

• Central to symptom management (Evidence A).
• Inhaled preferred over oral (Evidence A).
• SABA or SAMA improve FEV1 and symptoms (Evidence A).
• LABAs and LAMAs improve lung function, reduce exacerbations (Evidence A).
• Combination LABA+LAMA increases FEV1, reduces symptoms (Evidence A).

Anti-Inflammatory Therapy in Stable COPD

• ICS: Increases pneumonia risk (Evidence A), LABA+ICS improves lung function and reduces exacerbations in moderate to very severe COPD (Evidence A).
• Triple inhaled therapy (LABA+LAMA+ICS) improves outcomes (Evidence A).
  Other therapies like oral glucocorticoids, PDE inhibitors, antibiotics, and mucoregulators discussed as well.

Factors to Consider when Initiating ICS Treatment

• History of hospitalization(s) for exacerbations of COPD strongly favors use.
• \ge 2 moderate exacerbations of COPD per year* favors use.
• Blood eosinophils \ge 300 cells/\muL favors use.
  -Repeated pneumonia events Against use.
  -Blood eosinophils < 100 cells/\muL Against use.

Management of Patients Currently on LABA+ICS

-No current exacerbations previous positive treatment: Continue treatment
-Low symptom Load,Blood eosinophils < 100/\mu L Consider changing to LABA+LAMA
-High symptom load,Blood eosinophils \ge 100/\mu L Consider changing to LABA+LAMA+ICS

Other Pharmacological Treatments

• Alpha-1 Antitrypsin Augmentation Therapy, Antitussives, Vasodilators, Opioids, Pulmonary Hypertension Therapy

Pulmonary Rehabilitation, Self-Management and Integrative Care in COPD

Rehabilitation is indicated in all patients with relevant symptoms and/or a high risk for exacerbation.
Education is needed to change patient's knowledge but there is no evidence that used alone it will change patient behavior
Physical activity is a strong predictor of mortality