New Guidelines for COPD

They keep changing. . . are you up to speed?

by
Scott Cerreta, BS, RRT
Director of Education
www.copdfoundation.org
Conflict of Interest

I have no real or perceived conflict of

interest that relates to this presentation. Any
use of brand names is not in any way meant
to be an endorsement of a specific product,
but to merely illustrate a point of emphasis.
Objectives

1. Discuss different definitions of COPD

2. Discuss current literature and research that

warrants the need to change COPD Guidelines

3. Describe new features of the GOLD Guidelines

4. Describe how these changes will impact

diagnosis and treatment recommendations
1. GOLD Definition

COPD, a common preventable and

treatable disease, is characterized by
persistent airflow limitation that is usually
progressive and associated with an
enhanced chronic inflammatory response
in the airways and the lung to noxious
particles or gases.
Exacerbations and comorbidities
contribute to the overall severity in
individual patients.
ATS / ERS Definition

Chronic Obstructive Pulmonary Disease

(COPD) is a preventable and treatable
disease state characterised by airflow
limitation that is not fully reversible.
The airflow limitation is usually
progressive and associated with an
abnormal inflammatory response of the
lungs to noxious particles or gases,
primarily caused by cigarette smoking.
NHLBI Definition

Chronic Obstructive Pulmonary Disease

Serious lung disease that over time makes
it hard to breathe
Emphysema
Chronic Bronchitis
Blocked (obstructed) airways make it hard
to get air in and out
COPD Foundation Definition

Chronic Obstructive Pulmonary Disease

Serious lung disease that over time makes
it hard to breathe
Emphysema
Chronic Bronchitis
Refractory Asthma and
Some forms of bronchiectasis
Blocked (obstructed) airways make it hard
to get air in and out
 COPD: Definitions of 21st Century1

Chronic bronchitis Emphysema

Preventable and treatable

Airflow limitation that is not COPD
fully reversible
Progressive disease
Abnormal inflammatory
response of the lungs Asthma
Box = FEV1/FVC < 70% or < LLN

Subsets of patients Spirometry is REQUIRED for diagnosis

2. Literature Review

COPD Gene Study Dr. Crapo

Why some smokers get COPD & others dont
Using HRCT and identified a large number of
people with emphysema despite normal
spirometry
Spiromics Dr. Rennard
Identifying subsets of people with COPD
collection and analysis of phenotypic,
biomarker, genetic, genomic, and clinical data
from subjects with COPD
Observations from Experts

Not all forms of Emphysema or Chronic

Bronchitis are COPD.

Not all severities of COPD are the same

People with same FEV1 have different health
status, dyspnea scores, comorbidities,
exacerbation history, etc.
Dr. Vesbo, Chair of GOLD states:

Spirometry is essential for the diagnosis of

COPD, but it doesnt fully capture the impact of
the disease on individual patients
Example: Some patients with Moderate COPD
may have severe breathlessness, while others
may have Mild COPD but more prone to acute
exacerbations
Both groups require more aggressive therapy
than past guidelines would recommend
COPD HETEROGENEITY
Cote & Celli
PT # 1 PT # 2 PT # 3 PT # 4
58 y 62 y 69 y 72 y
FEV1: 28 % FEV1: 33% FEV1: 35% FEV1: 34%
MRC: 2/4 MRC: 2/4 MRC: 3/4 MRC: 4/4
PaO2: 70 mmHg PaO2: 57 mmHg PaO2: 66 mmHg PaO2: 60 mmHg
6MWD: 540 m 6MWD: 400 m 6MWD: 230 m 6MWD: 154 m
BMI: 30 BMI: 21 BMI: 34 BMI: 24
 GOLD Treatment of COPD
FEV1 / FVC < 70%

I: Mild II:Moderate III: Severe IV: Very Severe

FEV1>80% pred FEV1 50-80% pred FEV1 30-50% pred FEV1 < 30% pred or FEV1 <50%
predicted plus respiratory failure

Active Reduction of risk factor(s); influenza vaccination

Add short-acting bronchodilator when needed
Add regular treatment with one or more long-acting
bronchodilators: 2 agonists and anticholinergics
Add rehabilitation
Add ICS for repeated exacerbations

Add LTOT
Surgical interventions

http://www.goldcopd.org/
3. New Features Added in Dec 2011

GOLD Spirometry Classification Stays

NEW is Assessment Model ABCD
mMRC dyspnea scale or COPD Assessment
Test (CAT) health status
Spirometry classification and
Exacerbation History
 Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD

Assess symptoms
Assess degree of airflow
limitation using spirometry
Assess risk of exacerbations

Assess comorbidities
Global Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPD

(GOLD Classification of Airflow Limitation)

4
>2
(C) (D)

(Exacerbation history)
3

Risk
Risk

2
1
(A) (B)
1 0

mMRC 0-1 mMRC > 2

CAT < 10 CAT > 10
Symptoms
(mMRC or CAT score))
 Global Strategy for Diagnosis, Management and Prevention of COPD

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

Breathlessness Measurement using the

Modified British Medical Research Council
(mMRC) Questionnaire: relates well to other
measures of health status and predicts future
mortality risk.
 Tools: COPD Assessment Test (CAT)

Measures health status

Based on 8 questions

Score from 0 to 5

High scores = symptoms

May predict exacerbation

May reveal improvement after

attending Rehab

http://www.catestonline.org/english/index.htm
Global Strategy for Diagnosis, Management and Prevention of COPD

Modified MRC (mMRC)Questionnaire

 Global Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPD

Assess symptoms first

If mMRC 0-1 or CAT < 10:

(C) (D) Less Symptoms (A or C)

If mMRC > 2 or CAT > 10:

More Symptoms (B or D)
(A) (B)
mMRC 0-1 mMRC > 2
CAT < 10 CAT > 10
Symptoms
(mMRC or CAT score))
 Global Strategy for Diagnosis, Management and Prevention of COPD

Classification of Severity of Airflow

Limitation 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

 Global Strategy for Diagnosis, Management and Prevention of COPD

Assess Risk of Exacerbations

To assess risk of exacerbations use

history of exacerbations and
spirometry:
Two or more exacerbations within
the last year or an FEV1 < 50 % of
predicted value are indicators of
high risk.
Tease Out All Exacerbations

Must assess all exacerbations increase

in symptoms that requires change in tx
Hospitalizations
ER / Urgent Care visits
PCP / Pulmonologist visit

Ask about infection or use of antibiotics,

the most common cause of exacerbation
 Global Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPD

Assess risk of exacerbations next
(GOLD Classification of Airflow Limitation)

4
If GOLD 1 or 2 and only

(Exacerbation history)
3
(C) (D) >2 0 or 1 exacerbations per year:
Low Risk (A or B)
Risk

Risk
If GOLD 3 or 4 or two or
2 1 more exacerbations per year:
(A) (B) High Risk (C or D)
1 0

mMRC 0-1 mMRC > 2

CAT < 10 CAT > 10
Symptoms
(mMRC or CAT score))
 Global Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPD

Use combined assessment
(GOLD Classification of Airflow Limitation)

Patient is now in one of

4 four categories:

(Exacerbation history)
(C) (D) >2
3 A: Less symptoms, low risk
Risk

Risk
B: More symptoms, low risk
2 1
(A) (B) C: Less symptoms, high risk
1 0
D: More symptoms, high
mMRC 0-1 mMRC > 2 risk
CAT < 10 CAT > 10
Symptoms
(mMRC or CAT score))
 Global Strategy for Diagnosis, Management and
Prevention of COPD

Combined Assessment
of COPD
When assessing risk, choose the highest risk
according to GOLD grade or exacerbation history

Patient Characteristic Spirometric Exacerbations mMRC CAT

Classification per year
Low Risk
A GOLD 1-2 1 0-1 < 10
Less Symptoms
Low Risk
B GOLD 1-2 1 >2 10
More Symptoms
High Risk
C GOLD 3-4 >2 0-1 < 10
Less Symptoms
High Risk 10
D GOLD 3-4 >2 >2
More Symptoms
Maintenance Care vs. Acute Care

Typical hospitalization requires aggressive

medication management
Goal is to return patient to baseline
treatment recommendations
Maintenance Therapy requires the least
amount of medication to control patient
symptoms and health status
 Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
(Medications in each box are mentioned in alphabetical order, and
therefore not necessarily in order of preference.)

Patient First choice Second choice Alternative Choices

*LAMA
SAMA prn or
A or LABA Theophylline
SABA prn or
SABA and SAMA
*LAMA
SABA and/or SAMA
B or *LAMA and LABA
Theophylline
LABA
*ICS + LABA
*PDE4-inh.
or
C *LAMA and LABA SABA and/or SAMA
*LAMA
Theophylline

ICS and *LAMA or

*ICS + LABA
*ICS + LABA and *LAMA or Carbocysteine
or
D *ICS+LABA and *PDE4-inh. or SABA and/or SAMA
*LAMA
*LAMA and LABA or Theophylline
*LAMA and *PDE4-inh.
 Consequences Of COPD Exacerbations

Negative Impact on
impact on symptoms
quality of life and lung
function

EXACERBATIONS
Accelerated Increased
lung function economic
decline costs

Increased
Mortality
Scenario 1

Step 1: assess mMRC or CAT. mMRC=1

Left side, less symptoms
Step 2: assess spirometry = FEV1 43%
assess exacerbation hx = 2
Upper side, high risk
Assessment Score = C
Scenario 1

Old GOLD New GOLD

FEV1 = 43% FEV1 = 43%, Group C
Severe Stage 3 Less symp, Hi risk

Recommended Tx Recommended Tx
LABA or LAMA or ICS + LABA or LAMA
LABA + LAMA PDE4 inh.
ICS
Scenario 2

Step 1: assess mMRC or CAT. CAT=12

Right side, more symptoms
Step 2: assess spirometry = FEV1 81%
assess exacerbation hx = 0
Lower side, Low risk
Assessment Score = B
Scenario 2

Old GOLD New GOLD

FEV1 = 81% FEV1 = 81%, Group B
Mild Stage 1 More symp, Low risk

Recommended Tx Recommended Tx
SABA prn LAMA or LABA
Scenario 3

Step 1: assess mMRC or CAT. mMRC=4

Right side, more symptoms
Step 2: assess spirometry = FEV1 56%
assess exacerbation hx = 5
Upper side, High risk
Assessment Score = D
Scenario 3

Old GOLD New GOLD

FEV1 = 56% FEV1 = 56%, Group D
Moderate Stage 2 More symp, Hi risk

Recommended Tx Recommended Tx
SABA prn ICS + LABA or LAMA
LABA or LAMA or PDE4 inh.
LABA + LAMA Add everything else
 Global Strategy for Diagnosis, Management
and Prevention of COPD, 2011: Summary

Prevention of COPD is to a large extent possible

and should have high priority

Spirometry is required to make the diagnosis of

COPD; the presence of a post-bronchodilator
FEV1/FVC < 0.70 confirms the presence of
persistent airflow limitation and thus of COPD

The beneficial effects of pulmonary rehabilitation

and physical activity cannot be overstated
COPD HETEROGENEITY
Cote & Celli
PT # 1 PT # 2 PT # 3 PT # 4
58 y 62 y 69 y 72 y
FEV1: 28 % FEV1: 33% FEV1: 35% FEV1: 34%
MRC: 2/4 MRC: 2/4 MRC: 3/4 MRC: 4/4
PaO2: 70 mmHg PaO2: 57 mmHg PaO2: 66 mmHg PaO2: 60 mmHg
6MWD: 540 m 6MWD: 400 m 6MWD: 230 m 6MWD: 154 m
BMI: 30 BMI: 21 BMI: 34 BMI: 24
 Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Rehabilitation

All COPD patients benefit from exercise training

programs with improvements in exercise tolerance
and symptoms of dyspnea and fatigue.

Although an effective pulmonary rehabilitation

program is 6 weeks, the longer the program
continues, the more effective the results.

If exercise training is maintained at home the

patient's health status remains above pre-
rehabilitation levels.
COPD Pocket Consultant
Mobile App Coming Soon
Summary

Dx of COPD requires Spirometry but definitions

vary and change with new evidence
Tx of COPD requires new assessment
Spirometry, dyspnea score, exacerbation hx
and consider comorbidities
New ABCD assessment model is more accurate
and will improve pt outcomes
Learn how you can implement this model into
your system to decrease hospitalization rates
Thank You !
References
References
1. GOLD Guidelines http://www.goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html

2. COPD Gene Study http://www.copdgene.org/

3. Spiromics http://www.cscc.unc.edu/spir/

4. COPD Foundation http://www.copdfoundation.org