DIAGNOSIS MANAGEMENT AND PREVENTION A Guide for Health

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GLOBAL INITIATIVE FOR CHRONIC,OBSTRUCTIVE LUNG DISEASE. POCKET GUIDE TO COPD,DIAGNOSIS MANAGEMENT AND PREVENTION. A Guide for Health Care Professionals,2020 EDITION. 2020 Global Initiative for Chronic Obstructive Lung Disease Inc. GOLD BOARD OF DIRECTORS GOLD SCIENCE COMMITTEE, Alvar Agusti MD Chair Claus Vogelmeier MD Chair Maria Montes de Oca MD. Respiratory Institute University of Marburg Hospital Universitario de Caracas. Hospital Clinic IDIBAPS Marburg Germany Universidad Central de Venezuela. Univ Barcelona and Ciberes Caracas Venezuela,Barcelona Spain Alvar Agusti MD.
Respiratory Institute Hospital Alberto Papi MD, Richard Beasley MD Clinic IDIBAPS University of Ferrara. Medical Research Institute of NZ Univ Barcelona and Ciberes Ferrara Italy. Wellington New Zealand Barcelona Spain,Ian Pavord MA DM. Bartolome R Celli MD Antonio Anzueto MD Respiratory Medicine Unit and Oxford. Brigham and Women s Hospital South Texas Veterans Health Care System Respiratory NIHR Biomedical Research. Boston Massachusetts USA University of Texas Health Centre. San Antonio Texas USA Nuffield Department of Medicine. Rongchang Chen MD University of Oxford, Guangzhou Institute of Respiratory Peter Barnes DM FRS Oxford UK. Disease National Heart Lung Institute,Guangzhou PRC Imperial College Nicolas Roche MD. London United Kingdom University Paris Descartes,Gerard Criner MD H pital Cochin APHP.
Temple University School of Medicine Jean Bourbeau MD Paris France. Philadelphia Pennsylvania USA McGill University Health Centre. Montreal Canada Don D Sin MD, Peter Frith MD St Paul s Hospital University of British. Flinders University Gerard Criner MD Columbia, Adelaide Australia Temple University School of Medicine Vancouver Canada. Philadelphia Pennsylvania USA O,David Halpin MD Dave Singh MD. Royal Devon and Exeter Hospital Peter Frith MD retired 2019 University of Manchester. Devon UK Flinders University Manchester UK,Adelaide Australia. M Victorina L pez Varela MD Robert Stockley MD, Universidad de la Rep blica David Halpin MD University Hospital.
Montevideo Uruguay Royal Devon and Exeter Hospital Birmingham UK. Maria Montes de Oca MD M Victorina L pez Varela MD. Hospital Universitario de Caracas MeiLan Han MD MS Universidad de la Rep blica. Universidad Central de Venezuela University of Michigan Hospital Maciel. Caracas Venezuela Ann Arbor MI USA Montevideo Uruguay. Kevin Mortimer MD Fernando J Martinez MD MS J rgen Vestbo MD. Liverpool School of Tropical Medicine New York Presbyterian Hospital University of Manchester. Liverpool UK Weill Cornell Medical Center Manchester England UK. New York NY USA,Sundeep Salvi MD Jadwiga A Wedzicha MD. Chest Research Foundation Imperial College London,Pune India London UK. Claus Vogelmeier MD,University of Marburg,Marburg Germany. GOLD EXECUTIVE GOLD PROJECT MANAGER EDITORIAL ASSISTANCE. Rebecca Decker MSJ Katie Langefeld BS Ruth Hadfield PhD. Fontana Wisconsin USA Illinois USA Sydney Australia. Michael Hess MPH RRT RPFT,Kalamazoo MI USA, Disclosure forms for GOLD Committees are posted on the GOLD Website www goldcopd org. TABLE OF CONTENTS,TABLE OF CONTENTS III,MANAGEMENT OF STABLE COPD 28.
GLOBAL STRATEGY FOR THE DIAGNOSIS MANAGEMENT AND,OVERALL KEY POINTS 28. PREVENTION OF COPD 1,IDENTIFY AND REDUCE EXPOSURE TO RISK FACTORS 29. INTRODUCTION 1 TREATMENT OF STABLE COPD PHARMACOLOGICAL. TREATMENT 30,DEFINITION AND OVERVIEW 1, Algorithms for the assessment initiation and follow up. OVERALL KEY POINTS 1 management of pharmacological treatment 32. WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE TREATMENT OF STABLE COPD NON PHARMACOLOGICAL. COPD 1 TREATMENT 36,WHAT CAUSES COPD 2 Oxygen therapy 38. MONITORING AND FOLLOW UP 40,DIAGNOSIS AND ASSESSMENT OF COPD 3.
MANAGEMENT OF EXACERBATIONS 40,OVERALL KEY POINTS 3. DIAGNOSIS 4 OVERALL KEY POINTS 40,DIFFERENTIAL DIAGNOSIS 4 TREATMENT OPTIONS 42. ASSESSMENT 7 Treatment setting 42, Classification of severity of airflow limitation 8 Respiratory support 44. Assessment of symptoms 8 Hospital discharge and follow up 46. Combined COPD assessment 10,Prevention of exacerbations 47. EVIDENCE SUPPORTING PREVENTION AND MAINTENANCE COPD AND COMORBIDITIES 48. THERAPY 12,OVERALL KEY POINTS 48,OVERALL KEY POINTS 12 REFERENCES 48.
SMOKING CESSATION 12,VACCINATIONS 13,PHARMACOLOGICAL THERAPY FOR STABLE COPD 15. Overview of the medications 15,Bronchodilators 15,Antimuscarinic drugs 15. Methylxanthines 16,Combination bronchodilator therapy 16. Anti inflammatory agents 17,Inhaled corticosteroids ICS 17. Triple inhaled therapy 21,Oral glucocorticoids 21,Phosphodiesterase 4 PDE4 inhibitors 21.
Antibiotics 22, Mucolytic mucokinetics mucoregulators and antioxidant. agents NAC carbocysteine 22,Issues related to inhaled delivery 23. Other pharmacological treatments 23,REHABILITATION EDUCATION SELF MANAGEMENT 23. Pulmonary rehabilitation 23,SUPPORTIVE PALLIATIVE END OF LIFE HOSPICE CARE 24. Symptom control and palliative care 24,OTHER TREATMENTS 25.
Oxygen therapy and ventilatory support 25,Ventilatory Support 25. Surgical Interventions 25,GLOBAL STRATEGY FOR THE DIAGNOSIS MANAGEMENT AND. PREVENTION OF COPD,INTRODUCTION, Chronic Obstructive Pulmonary Disease COPD is currently the fourth leading cause of death in the world1 but is. projected to be the 3rd leading cause of death by 2020 More than 3 million people died of COPD in 2012 accounting. for 6 of all deaths globally COPD represents an important public health challenge that is both preventable and. treatable COPD is a major cause of chronic morbidity and mortality throughout the world many people suffer from. this disease for years and die prematurely from it or its complications Globally the COPD burden is projected to. increase in coming decades because of continued exposure to COPD risk factors and aging of the population 2. This Pocket Guide has been developed from the Global Strategy for the Diagnosis Management and Prevention. of COPD 2020 Report which aims to provide a non biased review of the current evidence for the assessment. diagnosis and treatment of patients with COPD that can aid the clinician Discussions of COPD and COPD. management evidence levels and specific citations from the scientific literature are included in that source. document which is available from www goldcopd org,DEFINITION AND OVERVIEW. OVERALL KEY POINTS, Chronic Obstructive Pulmonary Disease COPD is a common preventable and treatable disease.
that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway. and or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. The most common respiratory symptoms include dyspnea cough and or sputum production. These symptoms may be under reported by patients, The main risk factor for COPD is tobacco smoking but other environmental exposures such as. biomass fuel exposure and air pollution may contribute Besides exposures host factors predispose. individuals to develop COPD These include genetic abnormalities abnormal lung development and. accelerated aging, COPD may be punctuated by periods of acute worsening of respiratory symptoms called. exacerbations, In most patients COPD is associated with significant concomitant chronic diseases which increase. its morbidity and mortality, WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD. Chronic Obstructive Pulmonary Disease COPD is a common preventable and treatable disease that is characterized. by persistent respiratory symptoms and airflow limitation that is due to airway and or alveolar abnormalities usually. caused by significant exposure to noxious particles or gases and influenced by host factors including abnormal lung. development Significant comorbidities may have an impact on morbidity and mortality There may be significant. lung pathology e g emphysema in the absence of airflow limitation that needs further evaluation see Figure. WHAT CAUSES COPD, Worldwide the most commonly encountered risk factor for COPD is tobacco smoking Nonsmokers may also.
develop COPD COPD is the result of a complex interplay of long term cumulative exposure to noxious gases and. particles combined with a variety of host factors including genetics airway hyper responsiveness and poor lung. growth during childhood 3 5 The risk of developing COPD is related to the following factors. Tobacco smoke cigarette smokers have a higher prevalence of respiratory symptoms and lung function. abnormalities a greater annual rate of decline in FEV1 and a greater COPD mortality rate than non. smokers 6 Other types of tobacco e g pipe cigar water pipe 7 9 and marijuana10 are also risk factors for. COPD as well as environmental tobacco smoke ETS 11. Indoor air pollution resulting from the burning of wood and other biomass fuels used for cooking and. heating in poorly vented dwellings is a risk factor that particularly affects women in developing countries. Occupational exposures including organic and inorganic dusts chemical agents and fumes are under. appreciated risk factors for COPD 12 14, Outdoor air pollution also contributes to the lungs total burden of inhaled particles although it appears. to have a relatively small effect in causing COPD, Genetic factors such as severe hereditary deficiency of alpha 1 antitrypsin AATD 15 the gene encoding. matrix metalloproteinase 12 MMP 12 and glutathione S transferase have also been related to a decline in. lung function16 or risk of COPD 17, Age and sex aging and female sex increase COPD risk. Lung growth and development any factor that affects lung growth during gestation and childhood low. birth weight respiratory infections etc has the potential to increase an individual s risk of developing. Socioeconomic status Poverty is consistently associated with airflow obstruction18 and lower. socioeconomic status is associated with an increased risk of developing COPD 19 20 It is not clear however. whether this pattern reflects exposures to indoor and outdoor air pollutants crowding poor nutrition. infections or other factors related to low socioeconomic status. Asthma and airway hyper reactivity asthma may be a risk factor for the development of airflow limitation. Chronic bronchitis may increase the frequency of total and severe exacerbations 21. Infections a history of severe childhood respiratory infection has been associated with reduced lung. function and increased respiratory symptoms in adulthood 22. DIAGNOSIS AND ASSESSMENT OF COPD,OVERALL KEY POINTS. COPD should be considered in any patient who has dyspnea chronic cough or sputum production a. history of recurrent lower respiratory tract infections 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 FEV1 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 hospitalizations independently. 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 see Table Spirometry is required to make the diagnosis in this clinical. context23 the presence of a post bronchodilator FEV1 FVC 0 70 confirms the presence of persistent airflow. limitation and thus of COPD in patients with appropriate symptoms and significant exposures to noxious stimuli. Spirometry is the most reproducible and objective measurement of airflow limitation It is a noninvasive and readily. available test Despite its good sensitivity peak expiratory flow measurement alone cannot be reliably used as the. only diagnostic test because of its weak specificity 24. DIFFERENTIAL DIAGNOSIS, A major differential diagnosis is asthma In some patients with chronic asthma a clear distinction from COPD is not. possible using current imaging and physiological testing techniques In these patients current management is similar. to that of asthma Other potential diagnoses are usually easier to distinguish from COPD see Table. Alpha 1 antitrypsin deficiency AATD screening The World Health Organization recommends that all patients with. a diagnosis of COPD should be screened once especially in areas with high AATD prevalence 25 A low concentration. 20 normal is highly suggestive of homozygous deficiency Family members should also be screened. Additional investigations, The following additional investigations may be considered as part of the diagnosis and assessment of COPD. Imaging A chest X ray is not useful to establish a diagnosis in COPD but it is valuable in excluding alternative. diagnoses and establishing the presence of significant comorbidities such as concomitant respiratory pulmonary. fibrosis bronchiectasis pleural diseases skeletal e g kyphoscoliosis and cardiac diseases e g cardiomegaly. This Pocket Guide has been developed from the Global Strategy for the Diagnosis Management and Prevention of COPD 2020 Report which aims to provide a non biased review of the current evidence for the assessment diagnosis and treatment of patients with COPD that can aid the clinician Discussions of COPD and COPD management evidence levels and specific citations from the scientific

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