Global Initiative for Chronic Disease

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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

2019 REPORT

GLOBAL INITIATIVE FOR CHRONIC

OBSTRUCTIVE LUNG DISEASE

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POCKET GUIDE TO COPD DIAGNOSIS, MANAGEMENT, AND PREVENTION

A Guide for Health Care Professionals

2019 EDITION

? 2019 Global Initiative for Chronic Obstructive Lung Disease, Inc.

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GOLD SCIENCE COMMITTEE*

(2018)

GOLD BOARD OF DIRECTORS

(2018)

Alvar Agusti, MD, Chair

Respiratory Institute,

Hospital Clinic, IDIBAPS

Univ. Barcelona and Ciberes

Barcelona, Spain

Claus Vogelmeier, MD, Chair

University of Marburg

Marburg, Germany

Fernando J. Martinez, MD MS

New York-Presbyterian Hospital/

Weill Cornell Medical Center

New York, NY, USA

Bartolome R. Celli, MD

Brigham and Women¡¯s Hospital

Boston, Massachusetts, USA

Alvar Agusti, MD

Respiratory Institute, Hospital

Clinic, IDIBAPS

Univ. Barcelona and Ciberes

Barcelona, Spain

Rongchang Chen, MD

Guangzhou Institute of Respiratory

Disease

Guangzhou, PRC

Antonio Anzueto, MD

University of Texas

Health Science Center

San Antonio, Texas, USA

Gerard Criner, MD

Temple University School of Medicine

Philadelphia, Pennsylvania, USA

Peter Barnes, MD

National Heart and Lung Institute

London, United Kingdom

Peter Frith, MD

Flinders Hospital,

Adelaide, Australia

Jean Bourbeau, MD

McGill University Health Centre

Montreal, Canada

David Halpin, MD

Royal Devon and Exeter Hospital

Devon, UK

Gerard Criner, MD

Temple University School of Medicine

Philadelphia, Pennsylvania, USA

M. Victorina L¨®pez Varela, MD

Universidad de la Rep¨²blica

Montevideo, Uruguay

Maria Montes de Oca, MD

Hospital Universitario de Caracas

Caracas, Venezuela

Alberto Papi, MD

University of Ferrara

Ferrara, Italy

Ian Pavord, MA DM

University of Oxford

Oxford, UK

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Dave Singh, MD

University of Manchester

Manchester, UK

Peter Frith, MD

Repatriation General Hospital

Adelaide, Australia

J?rgen Vestbo, MD

University of Manchester

Manchester, England, UK

David Halpin, MD

Royal Devon and Exeter Hospital

Devon, United Kingdom

Jadwiga A. Wedzicha, MD

Imperial College London

London, UK

MeiLan Han, MD MS

University of Michigan

Ann Arbor, MI, USA

M. Victorina L¨®pez Varela,MD

Universidad de la Rep¨²blica

Hospital Maciel

Montevideo, Uruguay

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Claus Vogelmeier, MD

University of Marburg

Marburg, Germany

Donald Sin, MD

St. Paul¡¯s Hospital, University of

British Columbia

Vancouver, Canada

Robert Stockley, MD

University Hospital

Birmingham, UK

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Sundeep Salvi, MD

Chest Research Foundation

Pune, India

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Masaharu Nishimura, MD (retired May,

2018)

Hokkaido University School of Medicine

Sapporo, Japan

Nicolas Roche, MD

University Paris Descartes

H?pital Cochin APHP

Paris, France

GOLD PROGRAM DIRECTOR

Rebecca Decker, MSJ

Fontana, Wisconsin, USA

EDITORIAL ASSISTANCE

Ruth Hadfield, PhD, Sydney, Australia

Michael Hess, RRT RPFT, Michigan, USA

*

Disclosure forms for GOLD Committees are posted on the GOLD Website,

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TABLE OF CONTENTS

TABLE OF CONTENTS............................................. III

OTHER TREATMENTS ........................................... 22

Oxygen therapy and ventilatory support ........... 22

Ventilatory Support ........................................ 22

Surgical Interventions ..................................... 23

GLOBAL STRATEGY FOR THE DIAGNOSIS,

MANAGEMENT, AND PREVENTION OF COPD...............1

INTRODUCTION .....................................................1

MANAGEMENT OF STABLE COPD ............................. 24

DEFINITION AND OVERVIEW ......................................1

OVERALL KEY POINTS:..................................... 24

IDENTIFY AND REDUCE EXPOSURE TO RISK FACTORS

.......................................................................... 24

TREATMENT OF STABLE COPD: PHARMACOLOGICAL

TREATMENT ....................................................... 25

Algorithms for the assessment, initiation and

follow-up management of pharmacological

treatment ...................................................... 27

TREATMENT OF STABLE COPD: NONPHARMACOLOGICAL TREATMENT......................... 33

Education and self-management ..................... 33

Oxygen therapy .............................................. 34

MONITORING AND FOLLOW-UP............................ 36

OVERALL KEY POINTS: .......................................1

WHAT IS CHRONIC OBSTRUCTIVE PULMONARY

DISEASE (COPD)? ...................................................2

WHAT CAUSES COPD? ............................................2

DIAGNOSIS AND ASSESSMENT OF COPD .....................4

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OVERALL KEY POINTS: .......................................4

DIAGNOSIS............................................................4

DIFFERENTIAL DIAGNOSIS ......................................4

ASSESSMENT.........................................................5

Classification of severity of airflow limitation ......5

Assessment of symptoms...................................8

Combined COPD assessment ..............................8

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MANAGEMENT OF EXACERBATIONS......................... 36

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EVIDENCE SUPPORTING PREVENTION AND

MAINTENANCE THERAPY ...........................................9

COPD AND COMORBIDITIES ..................................... 44

OVERALL KEY POINTS: ..................................... 44

REFERENCES ....................................................... 44

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OVERALL KEY POINTS: .......................................9

SMOKING CESSATION .......................................... 10

VACCINATIONS.................................................... 10

PHARMACOLOGICAL THERAPY FOR STABLE COPD... 11

Overview of the medications............................ 11

Bronchodilators .............................................. 11

Antimuscarinic drugs....................................... 12

Methylxanthines ............................................. 14

Combination bronchodilator therapy ................ 14

Anti-inflammatory agents................................ 15

Inhaled corticosteroids (ICS)............................. 15

Triple inhaled therapy ..................................... 19

Oral glucocorticoids ........................................ 19

Phosphodiesterase-4 (PDE4) inhibitors.............. 19

Antibiotics ...................................................... 19

Mucolytic (mucokinetics, mucoregulators) and

antioxidant agents (NAC, carbocysteine)........... 20

Issues related to inhaled delivery...................... 20

Other pharmacological treatments................... 20

REHABILITATION, EDUCATION & SELF-MANAGEMENT

.......................................................................... 21

Pulmonary rehabilitation ................................. 21

SUPPORTIVE, PALLIATIVE, END-OF-LIFE & HOSPICE

CARE .................................................................. 21

Symptom control and palliative care................. 21

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OVERALL KEY POINTS:..................................... 36

TREATMENT OPTIONS ......................................... 37

Treatment setting........................................... 37

Respiratory support ........................................ 39

Hospital discharge and follow-up ..................... 41

Prevention of exacerbations ............................ 43

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GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT,

AND PREVENTION OF COPD

INTRODUCTION

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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

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This Pocket Guide has been developed from the Global Strategy for the Diagnosis, Management,

and Prevention of COPD (2019 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

.

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OVERALL KEY POINTS:

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DEFINITION AND OVERVIEW

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? 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.

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? 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.

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