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,
ii
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
iii
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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