POCKET GUIDE
TO COPD DIAGNOSIS, MANAGEMENT,
AND PREVENTION
A Guide for Health Care Professionals
REVISED DECEMBER 2006
Global Initiative for Chronic
Obstructive
Lung
Disease
Global Initiative for Chronic
Obstructive
Lung
Disease
Global Initiative for Chronic
Obstructive
Lung
Disease
POCKET_GUIDE_06 1/8/07 1:53 PM Page cov1
GOLD Executive Committee
A. Sonia Buist, MD, US, Chair
Antonio Anzueto, MD, US (representing ATS)
Peter Calverley, MD, UK
Teresita S. DeGuia, MD, Philippines
Yoshinosuke Fukuchi, MD, Japan (representing APSR)
Christine Jenkins, MD, Australia
Nikolai Khaltaev, MD, Switzerland (representing WHO)
James Kiley, PhD, US (representing NHLBI)
Ali Kocabas, MD, Turkey
Mara Victorina Lopez, MD, Uruguay (representing ALAT)
Klaus F. Rabe, MD, PhD, Netherlands
Roberto Rodriguez-Roisin, MD, Spain
Thys van der Molen, MD, Netherlands
Chris van Weel, MD, Netherlands (representing WONCA)
GOLD National Leaders
Representatives from many countries serve as a network for the dissemination and
implementation of programs for diagnosis, management, and prevention of COPD.
The GOLD Executive Committee is grateful to the many GOLD National Leaders who
participated in discussions of concepts that appear in GOLD reports, and for their
comments during the review of the 2006 Global Strategy for the Diagnosis,
Management, and Prevention of COPD.
Global Initiative for Chronic
Obstructive
Lung
Disease
Pocket Guide to COPD Diagnosis, Management,
and Prevention
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TABLE OF CONTENTS
PREFACE
KEY POINTS
WHAT IS CHRONIC OBSTRUCTIVE
PULMONARY DISEASE (COPD)?
RISK FACTORS: WHAT CAUSES COPD?
DIAGNOSING COPD
Figure 1: Key Indicators for Considering a
COPD Diagnosis
Figure 2: Normal Spirogram and Spirogram Typical of
Patients with Mild to Moderate COPD
Figure 3: Differential Diagnosis of COPD
COMPONENTS OF CARE:
A COPD MANAGEMENT PROGRAM
Component 1: Assess and Monitor Disease
Component 2: Reduce Risk Factors
Figure 4: Strategy to Help a Patient Quit Smoking
Component 3: Manage Stable COPD
Patient Education
Pharmacologic Treatment
Figure 5: Commonly Used Formulations of Drugs for COPD
Non-Pharmacologic Treatment
Figure 6: Therapy at Each Stage of COPD
Component 4: Manage Exacerbations
How to Assess the Severity of an Exacerbation
Home Management
Hospital Management
Figure 7: Indications for Hospital Admission
for Exacerbations
APPENDIX I: SPIROMETRY FOR DIAGNOSIS OF COPD
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5
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12
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15
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24
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Chronic Obstructive Pulmonary Disease (COPD) is a major cause of
chronic morbidity and mortality throughout the world. The Global
Initiative for Chronic Obstructive Lung Disease was created to
increase awareness of COPD among health professionals, public health
authorities, and the general public, and to improve prevention and
management through a concerted worldwide effort. The Initiative
prepares scientific reports on COPD, encourages dissemination and
adoption of the reports, and promotes international collaboration on
COPD research.
While COPD has been recognized for many years, public health officials
are concerned about continuing increases in its prevalence and mortality,
which are due in large part to the increasing use of tobacco products
worldwide and the changing age structure of populations in developing
countries. The Global Initiative for Chronic Obstructive Lung
Disease offers a framework for management of COPD that can be
adapted to local health care systems and resources. Educational tools,
such as laminated cards or computer-based learning programs, can be
prepared that are tailored to these systems and resources.
The Global Initiative for Chronic Obstructive Lung Disease
program includes the following publications:
• Global Strategy for the Diagnosis, Management, and Prevention of
COPD. Scientific information and recommendations for COPD
programs. (November 2006)
• Executive Summary, Global Strategy for the Diagnosis, Management,
and Prevention of COPD. (December 2006)
• Pocket Guide to COPD Diagnosis, Management, and Prevention.
Summary of patient care information for primary health care
professionals. (December 2006)
• What You and Your Family Can Do About COPD. Information booklet
for patients and their families.
PREFACE
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These publications are available on the Internet at
http://www.goldcopd.org. This site provides links to other websites
with information about COPD.
This Pocket Guide has been developed from the Global Strategy for the
Diagnosis, Management, and Prevention of COPD (2006). Technical
discussions of COPD and COPD management, evidence levels, and specific
citations from the scientific literature are included in that source document.
Acknowledgements: Grateful acknowledgement is given for the educational
grants from Altana Pharma, AstraZeneca, Boehringer Ingelheim, Chiesi,
GlaxoSmithKline, Merck, Sharp & Dohme, Mitsubishi-Tokyo, Novartis, Pfizer, and
Schering-Plough. The generous contributions of these companies assured that the
workshop participants could meet together and publications could be printed for
wide distribution. The workshop participants, however, are solely responsible for
the statements and conclusions in the publications.
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KEY POINTS
• Chronic Obstructive Pulmonary Disease (COPD) is a
preventable and treatable disease with some significant extra-
pulmonary effects that may contribute to the severity in individual
patients. Its pulmonary component is characterized by airflow limitation
that is not fully reversible. The airflow limitation is usually progressive
and associated with an abnormal inflammatory response of the lung
to noxious particles or gases.
• Worldwide, the most commonly encountered risk factor for COPD
is cigarette smoking. At every possible opportunity
individuals who smoke should be encouraged to quit. In
many countries, air pollution resulting from the burning of wood and
other biomass fuels has also been identified as a COPD risk factor.
• A diagnosis of 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. The diagnosis should be
confirmed by spirometry.
• A COPD management program includes four components:
assess and monitor disease, reduce risk factors, manage stable
COPD, and manage exacerbations.
• Pharmacologic treatment can prevent and control symptoms,
reduce the frequency and severity of exacerbations, improve health
status, and improve exercise tolerance.
• Patient education can help improve skills, ability to cope with
illness, and health status. It is an effective way to accomplish smoking
cessation, initiate discussions and understanding of advance directives
and end-of-life issues, and improve responses to acute exacerbations.
• COPD is often associated with exacerbations of symptoms.
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WHAT IS CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE
(COPD)?
Chronic Obstructive Pulmonary Disease (COPD) is a preventable
and treatable disease with some significant extrapulmonary effects that may
contribute to the severity in individual patients. Its pulmonary component
is characterized by airflow limitation that is not fully reversible. The air-
flow limitation is usually progressive and associated with an abnormal
inflammatory response of the lung to noxious particles or gases.
This definition does not use the terms chronic bronchitis and emphysema*
and excludes asthma (reversible airflow limitation).
Symptoms of COPD include:
• Cough
• Sputum production
• Dyspnea on exertion
Episodes of acute worsening of these symptoms often occur.
*Chronic bronchitis, defined as the presence of cough and sputum production for at least 3
months in each of 2 consecutive years, is not necessarily associated with airflow limitation.
Emphysema, defined as destruction of the alveoli, is a pathological term that is sometimes
(incorrectly) used clinically and describes only one of several structural abnormalities present
in patients with COPD.
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Chronic cough and sputum production often precede the
development of airflow limitation by many years, although
not all individuals with cough and sputum production go on
to develop COPD.
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RISK FACTORS:
WHAT CAUSES COPD?
Worldwide, cigarette smoking is the most commonly encountered risk
factor for COPD.
The genetic risk factor that is best documented is a severe hereditary
deficiency of alpha-1 antitrypsin. It provides a model for how other genetic
risk factors are thought to contribute to COPD.
COPD risk is related to the total burden of inhaled particles a person
encounters over their lifetime:
• Tobacco smoke, including cigarette, pipe, cigar, and other types of
tobacco smoking popular in many countries, as well as environmental
tobacco smoke (ETS)
• Occupational dusts and chemicals (vapors, irritants, and fumes) when
the exposures are sufficiently intense or prolonged
• Indoor air pollution from biomass fuel used for cooking and heating in
poorly vented dwellings, a risk factor that particularly affects women in
developing countries
• 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.
In addition, any factor that affects lung growth during gestation and
childhood (low birth weight, respiratory infections, etc.) has the potential
for increasing an individual’s risk of developing COPD.
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DIAGNOSING
COPD
A diagnosis of 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, especially cigarette smoking (Figure 1).
The diagnosis should be confirmed by spirometry* (Figure 2, page 9 and
Appendix I, page 24).
*Where spirometry is unavailable, the diagnosis of COPD should be made using all available
tools. Clinical symptoms and signs (abnormal shortness of breath and increased forced expira-
tory time) can be used to help with the diagnosis. A low peak flow is consistent with COPD but
has poor specificity since it can be caused by other lung diseases and by poor performance.
In the interest of improving the accuracy of a diagnosis of COPD, every effort should be made
to provide access to standardized spirometry.
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Figure 1: Key Indicators for Considering a COPD Diagnosis
Consider COPD, and perform spirometry, if any of these indicators are
present in an individual over age 40. These indicators are not diagnostic
themselves, but the presence of multiple key indicators increasees the
probability of a diagnosis of COPD.
• Dyspnea that is: Progressive (worsens over time).
Usually worse with exercise.
Persistent (present every day).
Described by the patient as an “increased effort
to breathe,” “heaviness,” “air hunger,” or
“gasping.”
• Chronic cough: May be intermittent and may be unproductive.
• Chronic sputum production:
Any pattern of chronic sputum production may
indicate COPD.
• History of exposure to risk factors:
Tobacco smoke (including popular local
preparations).
Occupational dusts and chemicals.
Smoke from home cooking and heating fuel.
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When performing spirometry, measure:
• Forced Vital Capacity (FVC) and
• Forced Expiratory Volume in one second (FEV1).
Calculate the FEV1/FVC ratio.
Spirometric results are expressed as % Predicted using
appropriate normal values for the person’s sex, age, and height.
9
Patients with COPD typically show a decrease in both FEV1
and FEV1/FVC. The degree of spirometric abnormality
generally reflects the severity of COPD. However, both
symptoms and spirometry should be considered when
developing an individualized management strategy for
each patient.
Figure 2: Normal Spirogram and Spirogram Typical of Patients
with Mild to Moderate COPD*
*Postbronchodilator FEV1 is recommended for the diagnosis
and assessment of severity of COPD.
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Stages of COPD
Stage I: Mild COPD - Mild airflow limitation (FEV1/FVC < 70%;
FEV1 ≥ 80% predicted) and sometimes, but not always, chronic cough
and sputum production.
• At this stage, the individual may not be aware that his or her lung
function is abnormal.
Stage II: Moderate COPD - Worsening airflow limitation
(FEV1/FVC < 70%; 50% ≤ FEV1 < 80% predicted), with shortness
of breath typically developing on exertion.
• This is the stage at which patients typically seek medical attention
because of chronic respiratory symptoms or an exacerbation of their
disease.
Stage III: Severe COPD - Further worsening of airflow limitation
(FEV1/FVC < 70%; 30% ≤ FEV1 < 50% predicted), greater shortness of
breath, reduced exercise capacity, and repeated exacerbations which
have an impact on patients’ quality of life.
Stage IV: Very Severe COPD - Severe airflow limitation
(FEV1/FVC < 70%; FEV1 < 30% predicted) or FEV1 < 50% predicted
plus chronic respiratory failure. Patients may have Very Severe (Stage IV)
COPD even if the FEV1 is > 30% predicted, whenever this complication
is present.
• At this stage, quality of life is very appreciably impaired and
exacerbations may be life-threatening.
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“At Risk for COPD”
A major objective of GOLD is to increase awareness among health care providers and the
general public of the significance of COPD symptoms. The classification of severity of COPD
now includes four stages classified by spirometry—Stage I: Mild COPD; Stage II: Moderate
COPD; Stage III: Severe COPD; Stage IV: Very Severe COPD. A fifth category—“Stage 0: At
Risk”—that appeared in the 2001 report is no longer included as a stage of COPD, as there
is incomplete evidence that the individuals who meet the definition of “At Risk” (chronic cough
and sputum production, normal spirometry) necessarily progress on to Stage I: Mild COPD.
Nevertheless, the importance of the public health message that chronic cough and sputum are
not normal is unchanged and their presence should trigger a search for underlying cause(s).
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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 (Figure 3).
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Diagnosis Suggestive Features*
COPD Onset in mid-life.
Symptoms slowly progressive.
Long smoking history.
Dyspnea during exercise.
Largely irreversible airflow limitation.
Asthma Onset early in life (often childhood).
Symptoms vary from day to day.
Symptoms at night/early morning.
Allergy, rhinitis, and/or eczema also present.
Family history of asthma.
Largely reversible airflow limitation.
Congestive Heart Failure Fine basilar crackles on auscultation.
Chest X-ray shows dilated heart, pulmonary edema.
Pulmonary function tests indicate volume restriction, not airflow
limitation.
Bronchiectasis Large volumes of purulent sputum.
Commonly associated with bacterial infection.
Coarse crackles/clubbing on auscultation.
Chest X-ray/CT shows bronchial dilation, bronchial wall thickening.
Tuberculosis Onset all ages.
Chest X-ray shows lung infiltrate or nodular lesions.
Microbiological confirmation.
High local prevalence of tuberculosis.
Obliterative Bronchiolitis Onset in younger age, nonsmokers.
May have history of rheumatoid arthritis or fume exposure.
CT on expiration shows hypodense areas.
Diffuse Panbronchiolitis Most patients are male and nonsmokers.
Almost all have chronic sinusitis.
Chest X-ray and HRCT show diffuse small centrilobular
nodular opacities and hyperinflation.
Figure 3: Differential Diagnosis of COPD
*These features tend to be characteristic of the respective diseases, but do not occur in
every case. For example, a person who has never smoked may develop COPD (especially
in the developing world, where other risk factors may be more important than cigarette
smoking); asthma may develop in adult and even elderly patients.
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COMPONENTS OF CARE:
A COPD MANAGEMENT
PROGRAM
The goals of COPD management include:
• Relieve symptoms
• Prevent disease progression
• Improve exercise tolerance
• Improve health status
• Prevent and treat complications
• Prevent and treat exacerbations
• Reduce mortality
• Prevent or minimize side effects from treatment.
Cessation of cigarette smoking should be included as a goal throughout
the management program.
THESE GOALS CAN BE ACHIEVED THROUGH
IMPLEMENTATION OF A COPD MANAGEMENT PROGRAM
WITH FOUR COMPONENTS:
1. Assess and Monitor Disease
2. Reduce Risk Factors
3. Manage Stable COPD
4. Manage Exacerbations
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Component 1: Assess and Monitor Disease
A detailed medical history of a new patient known or thought to
have COPD should assess:
• Exposure to risk factors, including intensity and duration.
• Past medical history, including asthma, allergy, sinusitis or nasal
polyps, respiratory infections in childhood, and other respiratory
diseases.
• Family history of COPD or other chronic respiratory disease.
• Pattern of symptom development.
• History of exacerbations or previous hospitalizations for
respiratory disorder.
• Presence of comorbidities, such as heart disease, malignancies,
osteoporosis, and musculoskeletal disorders, which may also
contribute to restriction of activity.
• Appropriateness of current medical treatments.
• Impact of disease on patient’s life, including limitation of activity;
missed work and economic impact; effect on family routines; and
feelings of depression or anxiety.
• Social and family support available to the patient.
• Possibilities for reducing risk factors, especially smoking cessation.
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In addition to spirometry, the following other tests should be under-
taken for the assessment of a patient with Moderate (Stage II), Severe
(Stage III), and Very Severe (Stage IV) COPD.
• Bronchodilator reversibility testing: To rule out a diagnosis of
asthma, particularly in patients with an atypical history (e.g., asthma
in childhood and regular night waking with cough and wheeze).
• Chest X-ray: Seldom diagnostic in COPD but valuable to exclude
alternative diagnoses such as pulmonary tuberculosis, and identify
comorbidities such as cardiac failure.
• Arterial blood gas measurement: Perform in patients with
FEV1 < 50% predicted or with clinical signs suggestive of respiratory
failure or right heart failure. The major clinical sign of respiratory
failure is cyanosis. Clinical signs of right heart failure include ankle
edema and an increase in the jugular venous pressure. Respiratory
failure is indicated by PaO2 < 8.0 kPa (60 mm Hg), with or without
PaCO2 > 6.7 kPa (50 mm Hg) while breathing air at sea level.
• Alpha-1 antitrypsin deficiency screening: Perform when
COPD develops in patients of Caucasian descent under 45 years or
with a strong family history of COPD.
COPD is usually a progressive disease. Lung function
can be expected to worsen over time, even with the best
available care. Symptoms and lung function should be
monitored to follow the development of complications, to
guide treatment, and to facilitate discussion of management
options with patients. Comorbidities are common in COPD
and should be actively identified.
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Component 2: Reduce Risk Factors
Smoking cessation is the single most effective—and