new gold guideline & cat

8/17/2019 New GOLD Guideline & CAT

1/48

GOLD Guideline 2011:Global Strategy for

Diagnosis, Management,

and Prevention of COPD


2/48

The GOLD document

• Chapter 1. Definition and overview

• Chapter 2. Diagnosis & assessment

• Chapter 3. Therapeutic options

• Chapter 4. Manage stable COPD

• Chapter 5. Manage exacerbations

• Chapter 6. COPD comorbidities


3/48

Definition of COPD

• COPD: a common preventable and treatabledisease, is characterized by persistent airflowlimitation that is usually progressive and

associated with an enhanced chronicinflammatory response in the airways and thelung to noxious particles or gases.

• Exacerbations and comorbidities contributeto the overall severity in individual patients.

Source: GOLD guideline 2011 Update


4/48

Prevention of COPDPrimary and Secondary

• A number of risk factors for COPD have been

identified – several of these enable primary

prevention of COPD; e.g., smoking, indoor air

pollution and poorly managed asthma.

• Smoking cessation is the single most important

intervention in the smoking COPD patient

• As COPD is the result of cumulative harmfulexposures, other exposures to dust, fumes and

smoke should be reduced whenever possible



5/48

Diagnosis of COPD

• A clinical diagnosis of COPD should be considered

in any patient who has dyspnea, chronic cough or

sputum production, and/or a history of exposure

to risk factors for the disease.

• Spirometry is required to make the diagnosis in

this clinical context; the presence of a post-

bronchodilator FEV1/FVC


6/48

Assessment of COPD

1. Assess symptoms

2. Assess degree of airflow limitation using spirometry

3. Assess risk of exacerbations

4. Assess comorbidities



7/48

Assessment of COPD

1. Assess symptoms




Use the COPD Assessment Test (CAT),

or the mMRC Breathlessness scale

Notes: The CAT score is preferred since it provides a more comprehensive

assessment of the symptomatic impact of the disease.



8/48

mMRC Dyspnoe scale

(modified Medical Research Council)

Tingkat1 Tidak terganggu oleh sesak napas kecualisaat olah-raga berat.

Tingkat

2

Terganggu dengan sesak napas ketika

terburu-buru berjalan di tanah yang datar

atau mendaki tanjakan.

Tingkat

3

Berjalan lebih lambat pada permukaan

yang datar dibandingkan orang seusia

karena sesak napas atau harus berhenti

untuk bernapas ketika berjalan pada

kecepatan sendiri di permukaan yang

datar.

Tingkat

4

Berhenti untuk bernapas setelah berjalan

90 meter atau setelah beberapa menit di

permukaan yang datar

Tingkat

5

Terlalu sesak untuk meninggalkan rumah

atau sesak saat berpakaian atau berganti

pakaian.


9/48


Assessment of COPD

1. Assess symptoms




Use spirometry for grading severity according

to spirometry, using four grades split at 80%,

50% and 30% of predicted value


10/48

Assessment of COPD

1. Assess symptoms



4. Assess comorbiditiesUse history of exacerbations & spirometry.

Two exacerbations or more within the last year

or an FEV1 < 50% of predicted value are

indicators of high risk



11/48

Assessment of COPD

1. Assess symptoms




Assess comorbidities and treat them

appropriately.

The most frequent comorbidities are CVD,depression and osteoporosis


12/48


13/48

R I S K

( G O L D C

l a s

s i f i c a t i o n o f

A i r f l o w L i

m i t a t i o n )

4 (C) (D)2 or

more

R I S

K

( E x a c e r b a t i o n h i s t o r y )

3

2 (A) (B) 1

1 0

mMRC 0-1 mMRC 2+

CAT


14/48

R I S K

( G O L D C

l a s

s i f i c a t i o n o f

A i r f l o w L i

m i t a t i o n )

4 (C) (D)2 or

more

R I S

K

( E x a c e r b a t i o n h i s t o r y )

3

2 (A) (B) 1

1 0

mMRC 0-1 mMRC 2+

CAT


15/48

Management of COPD – the aims

• Relieve symptoms

• Improve exercise tolerance

• Improve health status

• Prevent disease progression

• Prevent and treat exacerbations

• Reduce mortality

Reduce

symptoms

Reduce

risk



16/48

Management of COPDPharmacological First choice

GOLD 4

ICS + LABA or ICS + LABA or 2 ormore

GOLD 3

LAMA LAMA

GOLD 2

SABA or SAMA prn LABA or LAMA

1

GOLD 1 0

mMRC 0-1 mMRC 2+

CAT


17/48

GOLD 2009

GOLD

3 & 4

ICS + LABA or ICS + LABA or 2 or

moreLAMA LAMA

GOLD

1 & 2SABA or SAMA prn LABA or LAMA

0 - 1

mMRC 0-1 mMRC 2+CAT


18/48

Management of COPDPharmacological First alternatives

GOLD 4

LABA

ICS and LAMA

ICS/LABA and LAMA

ICS/LABA and PDE4-inh

LAMA and LABA

LAMA and PDE 4-inh

2 or

more

GOLD 3

and LAMA

GOLD 2LABA or

LAMA or

SABA and SAMALABA and LAMA

1

GOLD 1 0

mMRC 0-1 mMRC 2+

CAT


19/48

Management of COPDPharmacological

Patient First choice First alternatives Other alternatives

A SABA or SAMA prnLABA or LAMA or

SABA and SAMATheophylline

B LABA or LAMA LABA and LAMASABA and/or SAMA

Theophylline

CICS + LABA or

LAMALABA and LAMA

PDE4-inh

SABA and/or SAMA

Theophylline

DICS + LABA or

LAMA

ICS & LAMA or

ICS+LABA and LAMA or

ICS+LABA & PDE4-inh or

LABA and LAMA or

LAMA and PDE4-inh

Carbocysteine

SABA and/or SAMA

Theophylline



20/48

Management of COPDNon-pharmacological

Patient Essential RecommendedDepending on local

guidelines

ASmoking cessation (can include

pharmacological treatment)Physical activity

Flu vaccination

Pneumococcal

vaccination

B - D

Smoking cessation (can include

pharmacological treatment)

Pulmonary rehabilitation

Physical activity

Flu vaccination

Pneumococcal

vaccination



21/48

Bronchodilators - Recommendations

• For both ß2-agonists and anticholinergics, long-actingformulations are preferred over short-acting formulations(Evidence A).

• The combined use of SABA or LABA and anticholinergics

may be considered if symptoms are not improved withsingle agents (Evidence B).

• Based on efficacy and side effects inhaled bronchodilatorsare preferred over oral bronchodilators (Evidence A).

• Based on evidence of relatively low efficacy and more sideeffects, treatment with theophylline is not recommendedunless other long-term treatment bronchodilators areunavailable or unaffordable (Evidence B).



22/48

Steroid & PDE4 inhibitors - Recommendations

• There is no evidence to recommend a short-term therapeutic trial with

oral steroids in patients with COPD to identify those who will respond to

ICS or other medications.

• Long-term treatment with ICS is recommended for patients with severe

& very severe COPD and frequent exacerbations that are not adequately

controlled by long-acting bronchodilators (Evidence A).

• Long-term monotherapy with oral corticosteroid is not recommended in

COPD (Evidence A).

• Long-term monotherapy with ICS is not recommended in COPD because

it is less effective than combination of ICS with LABA (Evidence A).

• The PDE4 inh may also be used to reduce exacerbations for patients with

chronic bronchitis, severe and very severe COPD, and frequent

exacerbations that are not adequately controlled by long-acting

bronchodilators (Evidence B).



23/48

COPD and co-morbidities

COPD patients are at increased risk for: – Cardiovascular diseases a major comorbidity in COPD and probably

both the most frequent & most important disease coexisting with COPD

– Osteoporosis Osteoporosis & depression are also major comorbidities inCOPD & are often under-diagnosed & associated with poor QoL & prognosis

– Respiratory infections

– Anxiety and Depression

– Diabetes

– Lung cancer frequently seen in patients with COPD and has been found to bethe most frequent cause of death in patients with mild COPD

These co-morbid conditions may influence mortality and hospitalizations and

should be looked for routinely, and treated appropriately (as if the patient did

not have COPD).


24/48

2011 GOLD revision – Conclusions I

• Spirometry is required to make the diagnosis ofCOPD in clinical context; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the

presence of persistent airflow limitation and thusof COPD.

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

• Assessment of COPD requires assessment ofSymptoms, Degree of airflow limitation, Risk ofexacerbation, and Comorbidities



25/48

2011 GOLD revision – Conclusions II

• The combined assessment of symptoms and risk

of exacerbations is the basis for management of

COPD, both non-pharmacological and

pharmacological

• The beneficial effects of pulmonary rehabilitation

as well as physical activity cannot be overstated

• Comorbidities should be looked for – and ifpresent treated to the same extents as if the

patient did not have COPD.



26/48

Supported by an educational grant from GlaxoSmithKline

www.CATestonline.org

CAT – making simple patient

assessment a reality


27/48

The need for a simple tool to give patients and

physicians a common understanding and

grading of the impact of COPD

Significant numbers of patients have COPD that is under-recognised,untreated and sub-optimally managed, despite widening use ofspirometry1

– Exacerbations occur that go unreported2,3

– Physicians in general may under-treat patients with COPD, which can leadto poor QoL1

– Patients need help and support in realising and understanding the fullimpact of their disease1

– Physicians may not fully realise the extent to which COPD is limiting apatient’s life

QoL, quality of life

1. Confronting COPD in America: Executive Summary;

http://www.aarc.org/resources/confronting_copd/exesum.pdf; last accessed 13 August 2008.2. Wilkinson TM et al. Am J Respir Crit Care Med 2004;169:1298–1303.3. Seemungal TAR et al. Am J Respir Crit Care Med 1998;157:1418–1422.

A simple tool is needed to achieve a mutual understanding of disease status

and impact, and help to optimise disease management


28/48


29/48

Health status, FEV1 and GOLD

stage

FEV1, forced expiratory volume in 1 second; SGRQ, St George’s Respiratory Questionnaire.

1. Jones PW et al. Am Rev Respir Dis 1992;145:1321–1327.

0

20

40

60

80

100

10 20 30 40 50 60 70 80 90

Upper limit

of normal

SGRQ

score

Stage 4 Stage 3 Stage 2

FEV1 (% predicted)

Breathless

walking on

level

ground

r =–0.23

P


30/48

Correlation between CAT and

SGRQ-C (US, n=227)

0

5

10

15

20

25

30

35

40

0 10 20 30 40 50 60 70 80 90 100

CATscore

SGRQ-C score

r = 0.80

Jones et al. Eur Respir J 2009; 34: 648–654


31/48

C A T s c

o r e

Stablen=229

Exacerbationn=67

SD

P


32/48

The benefits of the CAT

The CAT is the only validated, short and simple

assessment questionnaire measuring the overall

COPD impact on patients

The CAT will ensure both physicians and patientsgain the understanding needed to manage COPD

optimally

The CAT will help detect changes with disease

progression and treatment


33/48

Cumulative distribution of CAT scores

(stable patients)

‘LowImpact’

‘MediumImpact’

‘HighImpact’

‘Very highImpact’

Percentage

of patients


34/48

Guidance is needed to aid clinicians’ understanding and interpretation of

patient scores

The CAT’s role in COPD management:understanding the score (I)

CAT

score

Impa

ct

level

Broad clinical picture of the impact of

COPD by CAT score

Possible management

considerations


35/48


patient scores

The CAT’s role in COPD management:understanding the score (II)

CAT

score

Impact

level


COPD by CAT score

Possible management

considerations

10-20 Mediu

m

COPD is one of the most important

problems the patients have.

They have a few good days a week, but

cough up sputum on most days and

have one or two exacerbations a year.

They are breathless on most days and

usually wake up with chest tightness or

wheeze.

They get breathless on bending over and

can only walk up a flight of stairs slowly.

They either do their housework slowly or

have to stop for rests.

Patient has room for improvement –

optimise management.

In addition to the guidance provided

for patients with low impact CAT

scores consider:

•Reviewing maintenance therapy –

is it optimal?

•Referral for pulmonaryrehabilitation

•Ensuring best approaches to

minimising and managing

exacerbations

•Reviewing aggravating factors – is

the patient still smoking?


36/48


patient scores

The CAT’s role in COPD management:understanding the score (III)

CAT

scor

e

Impac

t level

Broad clinical picture of the impact of COPD

by CAT score

Possible management

considerations

>20 High COPD stops them doing most things that

they want to do.

They are breathless walking around thehome and when getting washed or dressed.

They may be breathless when they talk.

Their cough makes them tired and their

chest symptoms disturb their sleep on most

nights.

They feel that exercise is not safe for themand everything they do seems too much

effort.

They are afraid and panic and do not feel in

control of their chest problem.

See next slide

(similar with CAT score >30)


37/48


patient scores

The CAT’s role in COPD management:understanding the score (IV)

CAT

score

Impact

level


COPD by CAT score

Possible management considerations

>30 Very

high

Their condition stops them doing

everything they want to do and they

never have any good days.

If they can manage to take a bath or

shower, it takes them a long time.

They cannot go out of the house for

shopping or recreation, or do their

housework.

Often, they cannot go far from their

bed or chair.

They feel as if they have become an

invalid.

Patient has significant room for

improvement

In addition to the guidance for patients

with low and medium impact CAT scores

consider:

• Referral to specialist care (if you are a

primary care physician)

Also consider:

• Additional pharmacological treatments

• Referral for pulmonary rehabilitation

• Ensuring best approaches to

minimising and managing

exacerbations


38/48

Supported by an educational grant from GlaxoSmithKline

www.CATestonline.org

Using CAT scores – what happens

over time?

Eff f b i 1 h


39/48

Better

Xu et al ERJ Express. Published on November 6, 2009 as doi: 10.1183/09031936.00079409

Change in

SGRQscore

Change in

CalculatedCAT

score

0

1

2

-2

-1

-3

Exacerbations

Effect of exacerbations on 1-year change

Calculated CAT score in hospitals clinics

in China


40/48

Limitations of the CAT

Nota diagnostic tool

Can be affected by co-morbidities (eg heart failure)

Does not remove need to make clinical

assessment

Is not totally comprehensive – patients’ lives can beaffected in more ways than listed in CAT

C CAT b d


41/48

Can CAT be used to set a target

score (like ACT in asthma)?

Fixed target for all patients

COPD is less reversible than asthma

Individual patient target

Aim for at least 2 unit improvement


42/48

Thank you for your kind

attentions


43/48

COPD Exacerbation

• An exacerbation of COPD is an acute event characterized by a

worsening of the patient’s respiratory symptoms that is beyond

normal day-to-day variations and leads to a change in medication

• Exacerbations of COPD can be precipitated by several factors. The

most common causes appear to be viral upper respiratory tractinfections and infection of the tracheobronchial tree.

• The diagnosis of an exacerbation relies exclusively of an acute

change of symptoms (baseline dyspnea, cough, and/or sputum

production) that is beyond normal day-to-day variation• The goal of treatment in COPD exacerbations is to minimize the

impact of the current exacerbation and to prevent the development

of subsequent exacerbations


44/48

COPD Exacerbation

• SABA with or without SAMA are usually the preferred

bronchodilators for treatment of an exacerbation.

• Systemic corticosteroid and antibiotics can shorten recovery time,

improve lung function (FEV1) and arterial hypoxemia (PaO2), and

reduce the risk of early relapse, treatment failure, and length ofhospital stay.

• COPD exacerbation can often be prevented. Smoking cessation,

influenza and pneumococcal vaccination, knowledge of current

therapy including inhaler technique, and treatment with long-actinginhaled bronchodilators, with or without ICS, and treatment with a

PDE-4 inh are all interventions that reduce the number of

exacerbation and hospitalization.


45/48


46/48

A one-off score can be used to test whether a patient’sscore is higher than expected

Proximity to the ‘usual value’ can indicate:

– whether the existing diagnosis is correct

– the presence of co-morbid condition(s)

High impact scores for certain elements of the CAT (for a givenFEV1) may indicate the need to introduce, or increase, anintervention

Longitudinal scores can be used to assess:whether a patient is responding to treatment(e.g. pulmonary rehabilitation study)

whether a patient is deteriorating

Lack of change in CAT score does not mean treatmentshould be stopped as improving health status is only oneaim of therapy

The CAT’s role in COPD management:

understanding the score (I)


47/48


patient scores

The CAT’s role in COPD management:understanding the score (II)

CAT

score

Impact

level

Broad clini cal picture of the impact of COPD by

CAT score



48/48


patient scores

The CAT’s role in COPD management:understanding the score (III)

CAT

score

Impact

level

Broad clin ical pictu re of the impact of COPD by CAT

score


>20

>30

High

Veryhigh

COPD stops them doing most things that they want to do.

They are breathless walking around the home and when

getting washed or dressed.

They may be breathless when they talk.

Their cough makes them tired and their chest symptomsdisturb their sleep on most nights.

They feel that exercise is not safe for them and everything

they do seems too much effort.

They are afraid and panic and do not feel in control of their

chest problem.

Their condition stops them doing everything they want to do

and they never have any good days.

If they can manage to take a bath or shower, it takes them a

long time.

They cannot go out of the house for shopping or recreation,

or do their housework.

Often, they cannot go far from their bed or chair.

They feel as if they have become an invalid.

Patient has significant room for improvement

In addition to the guidance for patients with

low and medium impact CAT scores consider:

• Referral to specialist care (if you are aprimary care physician)

Also consider:

• Additional pharmacological treatments

• Referral for pulmonary rehabilitation

• Ensuring best approaches to minimising

and managing exacerbations

new gold guideline & cat

Documents