Sandra G. Adams, MD, MS Pulmonary Diseases / Critical Care Medicine University of Texas Health Science Center at San Antonio South Texas Veterans Healthcare.

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Presentation transcript:

Sandra G. Adams, MD, MS Pulmonary Diseases / Critical Care Medicine University of Texas Health Science Center at San Antonio South Texas Veterans Healthcare System

GOLD Assessment Severity of Obstruction Post-bronchodilator FEV 1 /FVC <70% III: Severe FEV 1 30% to 49% IV: Very Severe FEV 1 <30% Worse obstruction Global initiative for chronic obstructive lung disease. GOLD Website. Updated December 2011http:// I: Mild FEV 1 80% II: Moderate FEV 1 50% to 79% FEV 1 = Forced expiratory volume in one second; FVC = Forced vital capacity High Risk

Modified Medical Research Council (MMRC) Dyspnea Scale GradeDescription of Breathlessness 0I only get breathless with strenuous exercise 1I get short of breath when hurrying on level ground or walking up a slight hill 2On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace 3I stop for breath after walking about 100 yards or after a few minutes on level ground 4I am too breathless to leave the house or I am breathless when dressing Global initiative for chronic obstructive lung disease. GOLD Website. Updated December 2011http://

GOLD Assessment Worse obstruction GOLD Website. Updated December 2011http:// I: Mild FEV 1 80% II: Moderate FEV 1 50% to 79% Symptoms More severe High Risk Modified Medical Research Council Dyspnea Score Severity of Obstruction Post-bronchodilator FEV 1 /FVC <70% III: Severe FEV 1 30% to 49% IV: Very Severe FEV 1 <30%

GOLD Assessment Worse obstruction GOLD Website. Updated December 2011http:// May consider high risk if develops 1 severe exacerbation or has been hospitalized for exacerbation (not part of GOLD report) I: Mild FEV 1 80% II: Moderate FEV 1 50% to 79% More severe Exacerbations 2 or more per year See below 1 per year Frequent exacerbations None High Risk SymptomsSymptoms Modified Medical Research Council Dyspnea Score Severity of Obstruction Post-bronchodilator FEV 1 /FVC <70% III: Severe FEV 1 30% to 49% IV: Very Severe FEV 1 <30%

GOLD Assessment Worse obstruction I: Mild FEV 1 80% II: Moderate FEV 1 50% to 79% More severe Exacerbations 1 per year Frequent exacerbations A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations None High Risk Symptoms Modified Medical Research Council Dyspnea Score Severity of Obstruction Post-bronchodilator FEV 1 /FVC <70% GOLD Website. Updated December 2011http:// 2 or more per year III: Severe FEV 1 30% to 49% IV: Very Severe FEV 1 <30%

GOLD Assessment Worse obstruction I: Mild FEV 1 80% II: Moderate FEV 1 50% to 79% More severe Exacerbations 1 per year Frequent exacerbations None High Risk Symptoms Modified Medical Research Council Dyspnea Score Severity of Obstruction Post-bronchodilator FEV 1 /FVC <70% B Mild-Mod Obstruction Severe Symptoms Few Exacerbations A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations 2 or more per year GOLD Website. Updated December 2011http:// III: Severe FEV 1 30% to 49% IV: Very Severe FEV 1 <30%

GOLD Assessment Worse obstruction I: Mild FEV 1 80% II: Moderate FEV 1 50% to 79% More severe Exacerbations 2 or more per year 1 per year Frequent exacerbations None C Severe Obstruction Minimal Symptoms ++ Exacerbations High Risk Symptoms Modified Medical Research Council Dyspnea Score Severity of Obstruction Post-bronchodilator FEV 1 /FVC <70% A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations B Mild-Mod Obstruction Severe Symptoms Few Exacerbations GOLD Website. Updated December 2011http:// III: Severe FEV 1 30% to 49% IV: Very Severe FEV 1 <30%

GOLD Assessment Worse obstruction I: Mild FEV 1 80% II: Moderate FEV 1 50% to 79% More severe Exacerbations 1 per year Frequent exacerbations D Severe Obstruction Severe Symptoms ++ Exacerbations None High Risk Symptoms Modified Medical Research Council Dyspnea Score Severity of Obstruction Post-bronchodilator FEV 1 /FVC <70% C Severe Obstruction Minimal Symptoms ++ Exacerbations A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations B Mild-Mod Obstruction Severe Symptoms Few Exacerbations 2 or more per year GOLD Website. Updated December 2011http:// III: Severe FEV 1 30% to 49% IV: Very Severe FEV 1 <30%

GOLD Assessment Severity of Airflow Obstruction Worse obstruction More severe Exacerbations Frequent exacerbations D Severe Obstruction Severe Symptoms ++ Exacerbations High Risk Symptoms C Severe Obstruction Minimal Symptoms ++ Exacerbations A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations B Mild-Mod Obstruction Severe Symptoms Few Exacerbations GOLD Website. Updated December 2011http://

Management: GOLD Overview Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) Active reduction of risk factors and administer vaccinations (influenza/pneumococcal) Increase physical activity Add short-acting bronchodilator (as needed) Add one or more long-acting bronchodilator(s): scheduled Add pulmonary rehabilitation Consider adding inhaled corticosteroid*** Consider PDE4-inhibitor PDE4-inhibitor = phosphodiesterase4 inhibitor ABCD ***Never use an inhaled corticosteroid as a single agent in patients with COPD (inhaled corticosteroids are not approved by the FDA as a single agent for COPD and they should always be prescribed with a long-acting bronchodilator) GOLD Website. Updated December 2011http://

Pharmacotherapy: Overview Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid*** Consider PDE4-inhibitor PDE4-inhibitor = phosphodiesterase4 inhibitor ABCD ***Never use an inhaled corticosteroid as a single agent in patients with COPD (inhaled corticosteroids are not approved by the FDA as a single agent for COPD and they should always be prescribed with a long-acting bronchodilator) GOLD Website. Updated December 2011http://

First Choice Pharmacotherapy Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) SABA (prn) Albuterol: ProAir ® Proventil ® Reli-On ® Ventolin ® Levalbuterol: Xopenex ® Pirbuterol: Maxair ® OR SAMA (prn) Ipratropium: Atrovent ® Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) SABA = short-acting beta 2 -agonist SAMA = short-acting muscarinic antagonist (anticholinergic) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ABCD GOLD Website. Updated December 2011http://

First Choice Pharmacotherapy Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) LABA (scheduled) Arformoterol: Brovana ® Formoterol: Foradil ® Perforomist ® Indacaterol: Arcapta ® Salmeterol: Serevent ® OR LAMA (scheduled) Tiotropium: Spiriva ® Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) LABA = long-acting beta 2 -agonist LAMA = long-acting muscarinic antagonist (anticholinergic) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ABCD GOLD Website. Updated December 2011http://

First Choice Pharmacotherapy Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) LABA or LAMA (scheduled) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) ICS/LABA* Budesonide/Formoterol (Symbicort ® ) Fluticasone/Salmeterol (Advair ® ) OR LAMA Tiotropium (Spiriva ® ) Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) ICS = inhaled corticosteroid LABA = long-acting beta 2 -agonist LAMA = long-acting muscarinic antagonist (anticholinergic) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ABCD *Mometasone/Formoterol (Dulera ® ) is another ICS/LABA agent available in the US, but is not yet FDA-approved for COPD GOLD Website. Updated December 2011http://

First Choice Pharmacotherapy Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) LABA or LAMA (scheduled) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) ICS/LABA or LAMA (scheduled) Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) ICS/LABA or LAMA (scheduled) ICS = inhaled corticosteroid LABA = long-acting beta 2 -agonist LAMA = long-acting muscarinic antagonist (anticholinergic) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ABCD GOLD Website. Updated December 2011http://

Pharmacotherapy (Second Choice) Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Second choice: SABA + SAMA (scheduled) or LABA or LAMA (scheduled) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA (scheduled) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) First choice: ICS/LABA or LAMA (scheduled) Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) First Choice: ICS/LABA or LAMA (scheduled) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ABCD GOLD Website. Updated December 2011http://

Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA Second choice: LABA + LAMA Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) First choice: ICS/LABA or LAMA Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) First Choice: ICS/LABA or LAMA Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ABCD GOLD Website. Updated December 2011http:// Pharmacotherapy (Second Choice)

Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) First choice: ICS/LABA or LAMA Second choice: LABA + LAMA or ICS + LAMA Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) First Choice: ICS/LABA or LAMA Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ABCD GOLD Website. Updated December 2011http:// Pharmacotherapy (Second Choice)

Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) First choice: ICS/LABA or LAMA Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) First Choice: ICS/LABA or LAMA Second choice: ICS/LABA + LAMA or ICS/LABA + PDE4-inh or LAMA + PDE4-inh Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ABCD GOLD Website. Updated December 2011http:// PDE4-inhibitor = phosphodiesterase4 inhibitor: Roflumilast (Daliresp ® ) Pharmacotherapy (Second Choice)

Pharmacotherapy (1 st & 2 nd Choices) Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Second choice: SABA + SAMA (scheduled) or LABA or LAMA (scheduled) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA Second choice: LABA + LAMA Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) First choice: ICS/LABA or LAMA Second choice: LABA + LAMA or ICS + LAMA Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) First Choice: ICS/LABA or LAMA Second choice: ICS/LABA + LAMA or ICS/LABA + PDE4-inh or LAMA + PDE4-inh Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ABCD GOLD Website. Updated December 2011http://

Pharmacotherapy (Summary) Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Second choice: SABA + SAMA (scheduled) or LABA or LAMA (scheduled) Consider Theophylline Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA Second choice: LABA + LAMA Consider Theophylline Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) First choice: ICS/LABA or LAMA Second choice: LABA + LAMA or ICS + LAMA Consider PDE4-inh or Consider Theophylline Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) First Choice: ICS/LABA or LAMA Second choice: ICS/LABA + LAMA or ICS/LABA + PDE4-inh or LAMA + PDE4-inh Consider Theophylline Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ABCD GOLD Website. Updated December 2011http://

Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( 2/yr) Stage: Severe-Very Severe Severe Symptoms Exacerbations (2/yr) Active reduction of risk factors Administer vaccinations (influenza/pneumococcal) Increase physical activity Add pulmonary rehabilitation ABCD GOLD Website. Updated December 2011http:// Consider evaluation for need for supplemental oxygen Non-pharmacological Management: GOLD Overview Consider surgical eval