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roumilast in moderate to severe COPD. G:0.-H : ]^_cA68gml`najm_mW]]:

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C. Inserts related to tables/gures and special topics

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8/16/2019 GOLD Report 2016


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!"#$%" '()%(*!+ ,#) (-* ./%!0#'/'1

2%0%!*2*0(1 %0. 3)*4*0(/#0 #, 5#3.

Much has changed in the 10 years since the rst GOLD

$(=3$1* =)06-) 14.-4"*A Q0. 4:" B+-*%09+9& 3-%-*","%4& -%8

?."$"%4+0% 0Q 7L?B* Y#0 =6B8!0,(?: H,!0 )#\3$ $(/!0!3.B6!8?0 3. 1,( 01$(.;1,0 4$3) 1,( 3$!;!.#8 $(%3))(.?#1!3.0#.? !.%3$=3$#1(0 .(Y R.3Y8(?;(:

Z.( 34 1,( 01$(.;1,0 Y#0 1,( 1$(#1)(.1 3B\(%1!/(0: H,(0(,#/( 0133? 1,( 1(01 34 1!)(* B61 #$( .3Y 3$;#.!F(? !.13 1Y3;$36=0j 3B\(%1!/(0 1,#1 #$( ?!$(%1(? 13Y#$?0 !))(?!#1(82$(8!(/!.; #.? $(?6%!.; 1,( !)=#%1 34 02)=13)0* #.?3B\(%1!/(0 1,#1 $(?6%( 1,( $!0R 34 #?/($0( ,(#81, (/(.101,#1 )#2 #44(%1 1,( =#1!(.1 #1 03)( =3!.1 !. 1,( 4616$(:

`LM#%($B#1!3.0 #$( #. (M#)=8( 34 06%, (/(.10:a H,!0()=,#0!F(0 1,( .((? 43$ %8!.!%!#.0 13 )#!.1#!. # 43%60 3.B31, 1,( 0,3$1W1($) #.? 83.;W1($) !)=#%1 34 +ZJ' 3. 1,(!$=#1!(.10:

7 0(%3.? 01$(.;1, 34 1,( 3$!;!.#8 01$#1(;2 Y#0 1,( 0!)=8(*!.16!1!/( 0201() 43$ %8#00!42!.; +ZJ' 0(/($!12: H,!0 Y#0B#0(? 6=3. 1,( KLN

_ #.? Y#0 %#88(? # 01#;!.; 0201()

B(%#60( !1 Y#0 B(8!(/(?* #1 1,( 1!)(* 1,#1 1,( )#\3$!12 34=#1!(.10 43883Y(? # =#1, 34 ?!0(#0( =$3;$(00!3. !. Y,!%, 1,(severity of the disease tracked the severity of the airow

8!)!1#1!3.: "6%, !0 .3Y R.3Y. #B361 1,( %,#$#%1($!01!%0 34

=#1!(.10 !. 1,( ?!44($(.1 9Z5' 01#;(0 r 43$ (M#)=8(* 1,(!$8(/(8 34 $!0R 34 (M#%($B#1!3.0* ,30=!1#8!F#1!3.* #.? ?(#1,:<3Y(/($ #1 #. !.?!/!?6#8 =#1!(.1 8(/(8* 1,( KLN

_ !0 #.

6.$(8!#B8( )#$R($ 34 1,( 0(/($!12 34 B$(#1,8(00.(00* (M($%!0(8!)!1#1!3.* #.? ,(#81, 01#160 !)=#!$)(.1: H,!0 $(=3$1 $(1#!.0the GOLD classication system because it is a predictor of

4616$( #?/($0( (/(.10* B61 1,( 1($) dI1#;(e !0 .3Y $(=8#%(?B2 d9$#?(:e

71 1,( 1!)( 34 1,( 3$!;!.#8 $(=3$1* !)=$3/()(.1 !. B31,02)=13)0 #.? ,(#81, 01#160 Y#0 # 9Z5' 1$(#1)(.13B\(%1!/(* B61 02)=13)0 #00(00)(.1 ?!? .31 ,#/( # ?!$(%1$(8#1!3. 13 1,( %,3!%( 34 )#.#;()(.1* #.? ,(#81, 01#160

measurement was a complex process largely conned13 %8!.!%#8 016?!(0: Q3Y* 1,($( #$( 0!)=8( #.? $(8!#B8(f6(01!3..#!$(0 ?(0!;.(? 43$ 60( !. $361!.( ?#!82 %8!.!%#8=$#%1!%(: H,(0( #$( #/#!8#B8( !. )#.2 8#.;6#;(0:H,(0( ?(/(83=)(.10 ,#/( (.#B8(? # .(Y #00(00)(.10201() 13 B( ?(/(83=(? 1,#1 ?$#Y0 13;(1,($ # )(#06$( 341,( !)=#%1 34 1,( =#1!(.1E0 02)=13)0 #.? #. #00(00)(.1 341,( =#1!(.1E0 $!0R 34 ,#/!.; # 0($!360 #?/($0( ,(#81, (/(.1!. 1,( 4616$(: G. 16$.* 1,!0 .(Y #00(00)(.1 0201() ,#0 8(?

13 1,( %3.01$6%1!3. 34 # .(Y #==$3#%, 13 )#.#;()(.1r 3.(

1,#1 )#1%,(0 #00(00)(.1 13 1$(#1)(.1 3B\(%1!/(0: H,( .(Y)#.#;()(.1 #==$3#%, %#. B( 60(? !. #.2 %8!.!%#8 0(11!.;#.2Y,($( !. 1,( Y3$8? #.? )3/(0 +ZJ' 1$(#1)(.1 13Y#$?0!.?!/!?6#8!F(? )(?!%!.( r )#1%,!.; 1,( =#1!(.1E0 1,($#=2)3$( %830(82 13 ,!0 3$ ,($ .((?0:

+,$3.!% ZB01$6%1!/( J68)3.#$2 '!0(#0( ̀ +ZJ'a* 1,( 436$1,8(#?!.; %#60( 34 ?(#1, !. 1,( Y3$8?_* $(=$(0(.10 #. !)=3$1#.1=6B8!% ,(#81, %,#88(.;( 1,#1 !0 B31, =$(/(.1#B8( #.? 1$(#1#B8(+ZJ' !0 # )#\3$ %#60( 34 %,$3.!% )3$B!?!12 #.? )3$1#8!121,$36;,361 1,( Y3$8?g )#.2 =(3=8( 0644($ 4$3) 1,!0 ?!0(#0(

43$ 2(#$0* #.? ?!( =$()#16$(82 4$3) !1 3$ !10 %3)=8!%#1!3.0:983B#882* 1,( +ZJ' B6$?(. !0 =$3\(%1(? 13 !.%$(#0( !. %3)!.;?(%#?(0 B(%#60( 34 %3.1!.6(? (M=306$( 13 +ZJ' $!0R4#%13$0 #.? #;!.; 34 1,( =3=68#1!3.]:

G. _llo* Y!1, 1,( %33=($#1!3. 34 1,( Q#1!3.#8 <(#$1* 56.;*#.? @833? G.01!161(* QG< #.? 1,( D3$8? <(#81, Z$;#.!F#1!3.*1,( 983B#8 G.!1!#1!/( 43$ +,$3.!% ZB01$6%1!/( 56.; '!0(#0(`9Z5'a Y#0 !)=8()(.1(?: G10 ;3#80 Y($( 13 !.%$(#0(#Y#$(.(00 34 1,( B6$?(. 34 +ZJ' #.? 13 !)=$3/( =$(/(.1!3.#.? )#.#;()(.1 34 +ZJ' 1,$36;, # %3.%($1(? Y3$8?Y!?((443$1 34 =(3=8( !./38/(? !. #88 4#%(10 34 ,(#81, %#$( #.? ,(#81,%#$( =38!%2: 7. !)=3$1#.1 #.? $(8#1(? ;3#8 Y#0 13 (.%36$#;(

;$(#1($ $(0(#$%, !.1($(01 !. 1,!0 ,!;,82 =$(/#8(.1 ?!0(#0(:

In 2001, GOLD released it rst report, =)06-) 14.-4"*A Q0.

4:" B+-*%09+9& 3-%-*","%4& -%8 ?."$"%4+0% 0Q 7L?B: H,!0$(=3$1 Y#0 .31 !.1(.?(? 13 B( # %3)=$(,(.0!/( 1(M1B33R3. +ZJ'* B61 $#1,($ 13 06))#$!F( 1,( %6$$(.1 01#1( 34the eld. It was developed by individuals with expertise in

+ZJ' $(0(#$%, #.? =#1!(.1 %#$( #.? Y#0 B#0(? 3. 1,(B(01W/#8!?#1(? %3.%(=10 34 +ZJ' =#1,3;(.(0!0 #1 1,#11!)(* #83.; Y!1, #/#!8#B8( (/!?(.%( 3. 1,( )301 #==$3=$!#1()#.#;()(.1 #.? =$(/(.1!3. 01$#1(;!(0: G1 =$3/!?(? 01#1(W34W1,(W#$1 !.43$)#1!3. #B361 +ZJ' 43$ =68)3.#$2 0=(%!#8!010#.? 31,($ !.1($(01(? =,20!%!#.0 #.? 0($/(? #0 # 036$%(?3%6)(.1 43$ 1,( =$3?6%1!3. 34 /#$!360 %3))6.!%#1!3.0 43$31,($ #6?!(.%(0* !.%86?!.; #. LM(%61!/( I6))#$2b* # J3%R(196!?( 43$ <(#81, +#$( J$34(00!3.#80* #.? # J#1!(.1 96!?(:

Immediately following the release of the rst GOLD report

!. ]^^_* 1,( 9Z5' @3#$? 34 '!$(%13$0 #==3!.1(? # I%!(.%(+3))!11((* %,#$;(? Y!1, R((=!.; 1,( 9Z5' ?3%6)(.106=W13W?#1( B2 $(/!(Y!.; =6B8!0,(? $(0(#$%,* (/#86#1!.; 1,(!)=#%1 34 1,!0 $(0(#$%, 3. 1,( )#.#;()(.1

/0()#.65(/#0

$%5]!)#60.

8/16/2019 GOLD Report 2016


M!!!

$(%3))(.?#1!3.0 !. 1,( 9Z5' ?3%6)(.10* #.? =301!.;2(#$82 6=?#1(0 34 1,(0( ?3%6)(.10 3. 1,( 9Z5' D(B0!1(:The rst update to the GOLD report was posted in July 2003,

B#0(? 3. =6B8!%#1!3.0 4$3) A#.6#$2 ]^^_ 1,$36;, '(%()B($]^^]: 7 0(%3.? 6=?#1( #==(#$(? !. A682 ]^^c* #.? # 1,!$?!. A682 ]^^i* (#%, !.%86?!.; 1,( !)=#%1 34 =6B8!%#1!3.0 4$3)

A#.6#$2 1,$36;, '(%()B($ 34 1,( =$(/!360 2(#$: G. A#.6#$2]^^i* 1,( 9Z5' I%!(.%( +3))!11(( !.!1!#1(? !10 Y3$R 13=$(=#$( # %3)=$(,(.0!/(82 6=?#1(? /($0!3. 34 1,( 9Z5'$(=3$1g !1 Y#0 $(8(#0(? !. ]^^m: H,( )(1,3?383;2 60(? 13%$(#1( 1,( #..6#8 6=?#1(? ?3%6)(.10* #.? 1,( ]^^m $(/!0!3.*#==(#$0 #1 1,( 4$3.1 34 (#%, /386)(:

'6$!.; 1,( =($!3? 4$3) ]^^m 13 ]^_^* #;#!. #..6#8 6=?#1(??3%6)(.10 Y($( =$(=#$(? #.? $(8(#0(? 3. 1,( 9Z5'D(B0!1(* #83.; Y!1, 1,( )(1,3?383;2 60(? 13 =$(=#$( 1,(?3%6)(.10 #.? 1,( 8!01 34 =6B8!0,(? 8!1($#16$( $(/!(Y(? 13(M#)!.( 1,( !)=#%1 3. $(%3))(.?#1!3.0 )#?( !. 1,( #..6#86=?#1(0: G. ]^^l* 1,( 9Z5' I%!(.%( +3))!11(( $(%3;.!F(?

1,#1 %3.0!?($#B8( .(Y !.43$)#1!3. Y#0 #/#!8#B8( =#$1!%68#$82$(8#1(? 13 ?!#;.30!0 #.? #==$3#%,(0 13 )#.#;()(.1 34COPD that warranted preparation of a signicantly revised$(=3$1: H,( Y3$R 3. 1,!0 .(Y $(/!0!3. Y#0 !)=8()(.1(? !.)!?W]^^l Y,!8( #1 1,( 0#)( 1!)( 1,( +3))!11(( =$(=#$(? 1,(]^_^ 6=?#1(:

G. I(=1()B($ ]^^l #.? !. "#2 #.? I(=1()B($ ]^_^ Y,!8(=$(=#$!.; 1,( #..6#8 6=?#1(? $(=3$10 `:442V``NNNO*0)8/028O0.* a* I%!(.%( +3))!11(( )()B($0 B(;#. 13 !?(.1!421,( 8!1($#16$( 1,#1 !)=#%1(? 3. )#\3$ $(%3))(.?#1!3.0*(0=(%!#882 43$ +ZJ' ?!#;.30!0 #.? )#.#;()(.1: +3))!11(()()B($0 Y($( #00!;.(? %,#=1($0 13 $(/!(Y 43$ =$3=30(?modications and soon reached consensus that the reportrequired signicant change to reach the target audiences

r 1,( ;(.($#8 =$#%1!1!3.($ #.? 1,( !.?!/!?6#80 !. %8!.!%0around the world who rst see patients who present with$(0=!$#13$2 02)=13)0 1,#1 %368? 8(#? 13 # ?!#;.30!0 34+ZJ': G. 1,( 06))($ 34 ]^_^ # Y$!1!.; %3))!11(( Y#0(01#B8!0,(? 13 =$3?6%( #. 3618!.( 34 =$3=30(? %,#=1($0*which was rst presented in a symposium for the EuropeanC(0=!$#13$2 I3%!(12 !. @#$%(83.#* ]^_^: H,( Y$!1!.;%3))!11(( %3.0!?($(? $(%3))(.?#1!3.0 4$3) 1,!0 0(00!3.1,$36;,361 4#88 ]^_^ #.? 0=$!.; ]^__: '6$!.; 1,!0 =($!3?1,( 9Z5' @3#$? 34 '!$(%13$0 #.? 9Z5' Q#1!3.#8 5(#?($0

Y($( =$3/!?(? 06))#$!(0 34 1,( )#\3$ .(Y ?!$(%1!3.0$(%3))(.?(?: '6$!.; 1,( 06))($ 34 ]^__ 1,( ?3%6)(.1Y#0 %!$%68#1(? 43$ $(/!(Y 13 9Z5' Q#1!3.#8 5(#?($0* #.?31,($ +ZJ' 3=!.!3. 8(#?($0 !. # /#$!(12 34 %36.1$!(0: H,(.#)(0 34 1,( !.?!/!?6#80 Y,3 06B)!11(? $(/!(Y0 #==(#$!. 1,( 4$3.1 34 1,!0 $(=3$1: G. I(=1()B($ ]^__ 1,( 9Z5'I%!(.%( +3))!11(( $(/!(Y(? 1,( %3))(.10 #.? )#?(nal recommendations. The report was launched duringa symposium hosted by the Asian Pacic Society ofC(0=!$383;2 !. Q3/()B($ ]^__:

_: H,!0 ?3%6)(.1 ,#0 B((. %3.0!?($#B82 0,3$1(.(? !. 8(.;1,B2 8!)!1!.; 13 +,#=1($ _ 1,( B#%R;$36.? !.43$)#1!3. 3.

+ZJ': C(#?($0 Y,3 Y!0, 13 #%%(00 )3$( %3)=$(,(.0!/(!.43$)#1!3. #B361 1,( =#1,3=,20!383;2 34 +ZJ' #$( $(4($$(?13 # /#$!(12 34 (M%(88(.1 1(M1B33R0 1,#1 ,#/( #==(#$(? !. 1,(8#01 ?(%#?(:

]: +,#=1($ ] !.%86?(0 !.43$)#1!3. 3. ?!#;.30!0 #.?assessment of COPD. The denition of COPD has not been

signicantly modied but has been reworded for clarity.

b: 700(00)(.1 34 +ZJ' !0 B#0(? 3. 1,( =#1!(.1E0 8(/(834 02)=13)0* 4616$( $!0R 34 (M#%($B#1!3.0* 1,( 0(/($!12of the spirometric abnormality, and the identication of

%3)3$B!?!1!(0: D,($(#0 0=!$3)(1$2 Y#0 =$(/!36082 60(? 13

06==3$1 # ?!#;.30!0 34 +ZJ'* 0=!$3)(1$2 !0 .3Y $(f6!$(? 13make a condent diagnosis of COPD.

4. The spirometric classication of airow limitation is

?!/!?(? !.13 436$ 9$#?(0 `9Z5' _* "!8?g 9Z5' ]* "3?($#1(gGOLD 3, Severe; and GOLD 4, Very Severe) using the xed

$#1!3* =301B$3.%,3?!8#13$ KLN_/FVC < 0.70, to dene airow

limitation. It is recognized that use of the xed ratio

`KLN_hKN+a )#2 8(#? 13 )3$( 4$(f6(.1 ?!#;.30(0 34 +ZJ'

!. 38?($ #?6810 Y!1, )!8? +ZJ' #0 1,( .3$)#8 =$3%(00 34aging affects lung volumes and ows, and may lead to under

?!#;.30!0 !. #?6810 236.;($ 1,#. ci 2(#$0: H,( %3.%(=1 3401#;!.; ,#0 B((. #B#.?3.(? #0 # 01#;!.; 0201() B#0(?

3. KLN_ #83.( Y#0 !.#?(f6#1( #.? 1,( (/!?(.%( 43$ #.#81($.#1!/( 01#;!.; 0201() ?3(0 .31 (M!01: H,( )301 0(/($(0=!$3)(1$!% 9$#?(* 9Z5' c* ?3(0 .31 !.%86?( $(4($(.%( 13$(0=!$#13$2 4#!86$( #0 1,!0 0(()(? 13 B( #. #$B!1$#$2 !.%860!3.:

i: 7 .(Y %,#=1($ `+,#=1($ ba 3. 1,($#=(61!% #==$3#%,(0 ,#0B((. #??(?: H,!0 !.%86?(0 ?(0%$!=1!/( !.43$)#1!3. 3. B31,=,#$)#%383;!% #.? .3.W=,#$)#%383;!% 1,($#=!(0* !?(.1!42!.;#?/($0( (44(%10* !4 #.2:

m: "#.#;()(.1 34 +ZJ' !0 =$(0(.1(? !. 1,$(( %,#=1($0j"#.#;()(.1 34 I1#B8( +ZJ' ̀ +,#=1($ cag "#.#;()(.1

34 +ZJ' LM#%($B#1!3.0 `+,#=1($ iag #.? +ZJ' #.?+3)3$B!?!1!(0 ̀ +,#=1($ ma* %3/($!.; B31, )#.#;()(.1 34%3)3$B!?!1!(0 !. =#1!(.10 Y!1, +ZJ' #.? 34 +ZJ' !. =#1!(.10Y!1, %3)3$B!?!1!(0:

n: G. +,#=1($ c* "#.#;()(.1 34 I1#B8( +ZJ'*$(%3))(.?(? #==$3#%,(0 13 B31, =,#$)#%383;!% #.?.3.W=,#$)#%383;!% 1$(#1)(.1 34 +ZJ' #$( =$(0(.1(?: H,(chapter begins with the importance of identication and

$(?6%1!3. 34 $!0R 4#%13$0: +!;#$(11( 0)3R( %3.1!.6(0 13 B(

2*(-#.#"#!+

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8/16/2019 GOLD Report 2016


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identied as the most commonly encountered risk factor for

+ZJ' #.? (8!)!.#1!3. 34 1,!0 $!0R 4#%13$ !0 #. !)=3$1#.1 01(=13Y#$? =$(/(.1!3. #.? %3.1$38 34 +ZJ': <3Y(/($* )3$(?#1# #$( ()($;!.; 13 $(%3;.!F( 1,( !)=3$1#.%( 34 31,($ $!0R4#%13$0 43$ +ZJ' 1,#1 0,368? B( 1#R(. !.13 #%%36.1 Y,($(=300!B8(: H,(0( !.%86?( 3%%6=#1!3.#8 ?6010 #.? %,()!%#80*

#.? !.?33$ #!$ =38861!3. 4$3) B!3)#00 %33R!.; #.? ,(#1!.;!. =33$82 /(.1!8#1(? ?Y(88!.;0 r 1,( 8#11($ (0=(%!#882 #)3.;Y3)(. !. ?(/(83=!.; %36.1$!(0:

o: G. =$(/!360 9Z5' ?3%6)(.10* $(%3))(.?#1!3.0 43$)#.#;()(.1 34 +ZJ' Y($( B#0(? 038(82 3. 0=!$3)(1$!%%#1(;3$2: <3Y(/($* 1,($( !0 %3.0!?($#B8( (/!?(.%( 1,#1 1,(8(/(8 34 KLN

_ !0 # =33$ ?(0%$!=13$ 34 ?!0(#0( 01#160 #.? 43$

1,!0 $(#03. 1,( )#.#;()(.1 34 01#B8( +ZJ' B#0(? 3.# 01$#1(;2 %3.0!?($!.; B31, ?!0(#0( !)=#%1 `?(1($)!.(?)#!.82 B2 02)=13) B6$?(. #.? #%1!/!12 8!)!1#1!3.a #.? 4616$($!0R 34 ?!0(#0( =$3;$(00!3. `(0=(%!#882 34 (M#%($B#1!3.0a !0$(%3))(.?(?:

l: +,#=1($ i* "#.#;()(.1 34 LM#%($B#1!3.0* =$(0(.10 #revised denition of a COPD exacerbation.

_^: +,#=1($ m* +3)3$B!?!1!(0 #.? +ZJ'* 43%60(0 3.%#$?!3/#0%68#$ ?!0(#0(0* 301(3=3$30!0* #.M!(12 #.??(=$(00!3.* 86.; %#.%($* !.4(%1!3.0* #.? )(1#B38!% 02.?$3)(#.? ?!#B(1(0:

__: 7JJLQ'Gtj H,( $(=3$1 '!#;.30!0 34 '!0(#0(0 34 +,$3.!% Airow Limitation: Asthma, COPD, and Asthma-COPD

Z/($8#= I2.?$3)( `7+ZIa ,#0 B((. #??(?:

5(/(80 34 (/!?(.%( #$( #00!;.(? 13 )#.#;()(.1$(%3))(.?#1!3.0 Y,($( #==$3=$!#1(: L/!?(.%( 8(/(80 #$(!.?!%#1(? !. B38?4#%( 12=( (.%830(? !. =#$(.1,(0(0 #41($ 1,($(8(/#.1 01#1()(.1 (:;:* ̀ Evidence Aa: H,( )(1,3?383;!%#8

!006(0 %3.%($.!.; 1,( 60( 34 (/!?(.%( 4$3) )(1#W#.#820(0Y($( %#$(46882 %3.0!?($(?: H,!0 (/!?(.%( 8(/(8 0%,()(`(LAPH %a ,#0 B((. 60(? !. =$(/!360 9Z5' $(=3$10* #.? Y#0!. 60( 1,$36;,361 1,( =$(=#$#1!3. 34 1,!0 ?3%6)(.1c:

Table A. Description of Levels of Evidence

Evidence Category Sources of Evidence .HKCECDCGE

% C365'-#O*5 %'62)'&&*5 2)#3&$ PC1>$R<

C#%7 9'5A ', 5323<

Evidence is from endpoints of well-designed RCTs that provide a consistent pattern ofndings in the population for which the recommendation is made.Category A requires substantial numbers of studies involving substantial numbers of43)2#%#4362$<

$C365'-#O*5 %'62)'&&*5 2)#3&$

PC1>$R< 0#-#2*5 9'5A ', 5323<

Evidence is from endpoints of intervention studies that include only a limited number', 432#*62$: 4'$27'% ') $(9=)'(4 363&A$#$ ', C1>$: ') -*23D363&A$#$ ', C1>$< Q6

general, Category B pertains when few randomized trials exist, they are small in size,27*A ;*)* (65*)23Y*6 #6 3 4'4(&32#'6 2732 5#,,*)$ ,)'- 27* 23)=*2 4'4(&32#'6 ', 27*

)*%'--*6532#'6: ') 27* )*$(&2$ 3)* $'-*;732 #6%'6$#$2*62<

5X'6)365'-#O*5 2)#3&$<

/9$*)B32#'63& $2(5#*$<Evidence is from outcomes of uncontrolled or nonrandomized trials or from'9$*)B32#'63& $2(5#*$

. K36*& 1'6$*6$($ Z(5=-*62<

>7#$ %32*=')A #$ ($*5 '6&A #6 %3$*$ ;7*)* 27* 4)'B#$#'6 ', $'-* =(#536%* ;3$ 5**-*5

valuable but the clinical literature addressing the subject was deemed insufcient to [($2#,A 4&3%*-*62 #6 '6* ', 27* '27*) %32*=')#*$< >7* K36*& 1'6$*6$($ #$ 93$*5 '6

clinical experience or knowledge that does not meet the above-listed criteria

"*4*"' #, *4/.*05*

8/16/2019 GOLD Report 2016


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:

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'*"+*$",

8/16/2019 GOLD Report 2016


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]*+ 3#/0('j

• 7:.0%+/ L694.#/4+$" ?#),0%-.A B+9"-9" a7L?Bb&

- /0,,0% 2."$"%4-6)" -%8 4."-4-6)" 8+9"-9"& +9characterized by persistent airow limitation that is

#9#-))A 2.0*."99+$" -%8 -990/+-4"8 N+4: -% "%:-%/"8

chronic inammatory response in the airways and the

)#%* 40 %0H+0#9 2-.4+/)"9 0. *-9"9O KH-/".6-4+0%9

-%8 /0,0.6+8+4+"9 /0%4.+6#4" 40 4:" 0$".-)) 9"$".+4A +%

+%8+$+8#-) 2-4+"%49O

• +ZJ' !0 # 8(#?!.; %#60( 34 )3$B!?!12 #.? )3$1#8!12Y3$8?Y!?( #.? $(06810 !. #. (%3.3)!% #.? 03%!#8B6$?(. 1,#1 !0 B31, 06B01#.1!#8 #.? !.%$(#0!.;:

• G.,#8(? %!;#$(11( 0)3R( #.? 31,($ .3M!360 =#$1!%8(006%, #0 0)3R( 4$3) B!3)#00 46(80 %#60( 86.;inammation, a normal response that appears to be

modied in patients who develop COPD. This chronicinammatory response may induce parenchymal

1!006( ?(01$6%1!3. `$(0681!.; !. ()=,20()#a* #.??!0$6=1 .3$)#8 $(=#!$ #.? ?(4(.0( )(%,#.!0)0(resulting in small airway brosis). These pathological

changes lead to air trapping and progressive airow

8!)!1#1!3.* #.? !. 16$. 13 B$(#1,8(00.(00 #.? 31,($%,#$#%1($!01!% 02)=13)0 34 +ZJ':

7:.0%+/ L694.#/4+$" ?#),0%-.A B+9"-9" a7L?Bb& - /0,,0% 2."$"%4-6)" -%8 4."-4-6)" 8+9"-9"& +9 /:-.-/4".+>"8 6A persistent airow limitation that is usually progressive andassociated with an enhanced chronic inammatory response+% 4:" -+.N-A9 -%8 4:" )#%* 40 %0H+0#9 2-.4+/)"9 0. *-9"9OKH-/".6-4+0%9 -%8 /0,0.6+8+4+"9 /0%4.+6#4" 40 4:" 0$".-))9"$".+4A +% +%8+$+8#-) 2-4+"%49O

The chronic airow limitation characteristic of COPD is%#60(? B2 # )!M16$( 34 0)#88 #!$Y#20 ?!0(#0( `3B01$6%1!/(B$3.%,!38!1!0a #.? =#$(.%,2)#8 ?(01$6%1!3. ̀ ()=,20()#a*1,( $(8#1!/( %3.1$!B61!3.0 34 Y,!%, /#$2 4$3) =($03.13 =($03. `,CF@JH :S:). Chronic inammation causes

01$6%16$#8 %,#.;(0 #.? .#$$3Y!.; 34 1,( 0)#88 #!$Y#20:Destruction of the lung parenchyma, also by inammatory=$3%(00(0* 8(#?0 13 1,( 8300 34 #8/(38#$ #11#%,)(.10 13 1,(0)#88 #!$Y#20 #.? ?(%$(#0(0 86.; (8#01!% $(%3!8g !. 16$.*1,(0( %,#.;(0 ?!)!.!0, 1,( #B!8!12 34 1,( #!$Y#20 13 $()#!.open during expiration. Airow limitation is best measuredB2 0=!$3)(1$2* #0 1,!0 !0 1,( )301 Y!?(82 #/#!8#B8(*$(=$3?6%!B8( 1(01 34 86.; 46.%1!3.:

Many previous denitions of COPD have emphasized the1($)0 d()=,20()#e #.? d%,$3.!% B$3.%,!1!0*e Y,!%, #$(not included in the denition used in this or earlier GOLD

$(=3$10: L)=,20()#* 3$ ?(01$6%1!3. 34 1,( ;#0W(M%,#.;!.;06$4#%(0 34 1,( 86.; `#8/(38!a* !0 # =#1,383;!%#8 1($) 1,#1!0 341(. `B61 !.%3$$(%182a 60(? %8!.!%#882 #.? ?(0%$!B(0

3.82 3.( 34 0(/($#8 01$6%16$#8 #B.3$)#8!1!(0 =$(0(.1 !.=#1!(.10 Y!1, +ZJ': +,$3.!% B$3.%,!1!0* 3$ 1,( =$(0(.%(34 %36;, #.? 0=616) =$3?6%1!3. 43$ #1 8(#01 b )3.1,0 !.(#%, 34 1Y3 %3.0(%61!/( 2(#$0* $()#!.0 # %8!.!%#882 #.?(=!?()!383;!%#882 60(468 1($): <3Y(/($* !1 !0 !)=3$1#.113 $(%3;.!F( 1,#1 %,$3.!% %36;, #.? 0=616) =$3?6%1!3.`%,$3.!% B$3.%,!1!0a !0 #. !.?(=(.?(.1 ?!0(#0( (.1!12that may precede or follow the development of airow

8!)!1#1!3. #.? )#2 B( #003%!#1(? Y!1, ?(/(83=)(.1 #.?hor acceleration of xed airow limitation. Chronic bronchitis#803 (M!010 !. =#1!(.10 Y!1, .3$)#8 0=!$3)(1$2:

+ZJ' !0 # 8(#?!.; %#60( 34 )3$B!?!12 #.? )3$1#8!12Y3$8?Y!?( #.? $(06810 !. #. (%3.3)!% #.? 03%!#8B6$?(. 1,#1 !0 B31, 06B01#.1!#8 #.? !.%$(#0!.;]*i: +ZJ'=$(/#8(.%(* )3$B!?!12* #.? )3$1#8!12 /#$2 #%$300 %36.1$!(0#.? #%$300 ?!44($(.1 ;$36=0 Y!1,!. %36.1$!(0: +ZJ' !0 1,($(0681 34 %6)68#1!/( (M=306$(0 3/($ ?(%#?(0: Z41(.* 1,(=$(/#8(.%( 34 +ZJ' !0 ?!$(%182 $(8#1(? 13 1,( =$(/#8(.%(

34 13B#%%3 0)3R!.;* #81,36;, !. )#.2 %36.1$!(0* 361?33$*3%%6=#1!3.#8 #.? !.?33$ #!$ =38861!3. r 1,( 8#11($ $(0681!.;4$3) 1,( B6$.!.; 34 Y33? #.? 31,($ B!3)#00 46(80 r #$()#\3$ +ZJ' $!0R 4#%13$0m: H,( =$(/#8(.%( #.? B6$?(. 34+ZJ' #$( =$3\(%1(? 13 !.%$(#0( !. 1,( %3)!.; ?(%#?(0?6( 13 %3.1!.6(? (M=306$( 13 +ZJ' $!0R 4#%13$0 #.? 1,(%,#.;!.; #;( 01$6%16$( 34 1,( Y3$8?E0 =3=68#1!3. `Y!1, )3$(=(3=8( 8!/!.; 83.;($ #.? 1,($(43$( (M=$(00!.; 1,( 83.;W1($)(44(%10 34 (M=306$( 13 +ZJ' $!0R 4#%13$0ai: G.43$)#1!3.3. 1,( B6$?(. 34 +ZJ' %#. B( 436.? 3. !.1($.#1!3.#8

5-%3(*) :Y .*,/0/(/#0 %0. #4*)4/*?

.*,/0/(/#0

$6).*0 #, 5#3.

,CF@JH :S:S 2HMNLECIBI 6EOHJPQCEF

Airow Limitation in COPD

@-3&& 3#);3A$ 5#$*3$*

Airway inammationAirway brosis; luminal plugsQ6%)*3$*5 3#);3A )*$#$236%*

K3)*6%7A-3& 5*$2)(%2#'6

0'$$ ', 3&B*'&3) 3223%7-*62$

"*%)*3$* ', *&3$2#% )*%'#&

%/),"#? "/2/(%(/#0

8/16/2019 GOLD Report 2016


BKJIPIGILP <PB LEK@EIKF b

D(B0!1(0 06%, #0 1,30( 34 1,( ?GJPO -HLPDN #JFLEC^LDCGE7?-#< a:442V``NNNON:0O+%4b #.? 1,( ?GJPO $LE_`?-#!PGALP $@JOHE GK .CIHLIH 'D@OQ a:442V``NNNON:0O+%4`402+/9` *)06-)c6#.8"%c0Qc8+9"-9"bO 7;!.; !10(84 !0 # $!0R 4#%13$ 43$+ZJ' #.? #;!.; 34 1,( #!$Y#20 #.? =#$(.%,2)# )!)!%03)( 34 1,( 01$6%16$#8 %,#.;(0 #003%!#1(? Y!1, +ZJ'n:

Prevalence

LM!01!.; +ZJ' =$(/#8(.%( ?#1# 0,3Y $()#$R#B8( /#$!#1!3.?6( 13 ?!44($(.%(0 !. 06$/(2 )(1,3?0* ?!#;.301!% %$!1($!#*#.? #.#821!% #==$3#%,(0o: H,( 83Y(01 (01!)#1(0 34=$(/#8(.%( #$( 1,30( B#0(? 3. 0(84W$(=3$1!.; 34 # ?3%13$?!#;.30!0 34 +ZJ' 3$ (f6!/#8(.1 %3.?!1!3.: K3$ (M#)=8(*)301 .#1!3.#8 ?#1# 0,3Y 1,#1 8(00 1,#. mu 34 1,( #?681=3=68#1!3. ,#0 B((. 138? 1,#1 1,(2 ,#/( +ZJ'o: H,!0likely reects the widespread under-recognition and under-?!#;.30!0 34 +ZJ'l:

'(0=!1( 1,( %3)=8(M!1!(0* ?#1# #$( ()($;!.; 1,#1

(.#B8( 03)( %3.%860!3.0 13 B( ?$#Y. $(;#$?!.; +ZJ'=$(/#8(.%(* .31 8(#01 B(%#60( 34 !.%$(#0!.; ?#1# f6#8!12%3.1$38: 7 0201()#1!% $(/!(Y #.? )(1#W#.#820!0 34 016?!(0%#$$!(? 361 !. ]o %36.1$!(0 B(1Y((. _ll^ #.? ]^^co* #.?#. #??!1!3.#8 016?2 4$3) A#=#._^* =$3/!?( (/!?(.%( 1,#11,( =$(/#8(.%( 34 +ZJ' !0 #==$(%!#B82 ,!;,($ !. 0)3R($0#.? (MW0)3R($0 1,#. !. .3.0)3R($0* !. 1,30( 3/($ c^2(#$0 34 #;( 1,#. 1,30( 6.?($ c^* #.? !. )(. 1,#. !.Y3)(.: H,( 5#1!. 7)($!%#. J$3\(%1 43$ 1,( G./(01!;#1!3.34 ZB01$6%1!/( 56.; '!0(#0( `J57HGQZa__ (M#)!.(? 1,(prevalence of post-bronchodilator airow limitation amongpersons over age 40 in ve major Latin American cities,(#%, !. # ?!44($(.1 %36.1$2 r @$#F!8* +,!8(* "(M!%3* -$6;6#2*

#.? N(.(F6(8#: G. (#%, %36.1$2* 1,( =$(/#8(.%( 34 +ZJ'!.%$(#0(? 01((=82 Y!1, #;(* Y!1, 1,( ,!;,(01 =$(/#8(.%(#)3.; 1,30( 3/($ #;( m^* $#.;!.; !. 1,( 131#8 =3=68#1!3.4$3) # 83Y 34 n:ou !. "(M!%3 +!12* "(M!%3 13 # ,!;, 34_l:nu !. "3.1(/!?(3* -$6;6#2: G. #88 %!1!(0h%36.1$!(0 1,(=$(/#8(.%( Y#0 #==$(%!#B82 ,!;,($ !. )(. 1,#. !. Y3)(.__*which contrasts with ndings from European cities such#0 I#8FB6$;_]: H,( @6$?(. 34 ZB01$6%1!/( 56.; '!0(#0(0=$3;$#) `@Z5'a ,#0 %#$$!(? 361 06$/(20 !. 0(/($#8 =#$10 341,( Y3$8?_b #.? ,#0 ?3%6)(.1(? )3$( 0(/($( ?!0(#0( 1,#.=$(/!36082 436.? #.? # 06B01#.1!#8 =$(/#8(.%( `bW__ua 34+ZJ' #)3.; .(/($W0)3R($0:

2GJACOCDQ

"3$B!?!12 )(#06$(0 1$#?!1!3.#882 !.%86?( =,20!%!#. /!0!10*()($;(.%2 ?(=#$1)(.1 /!0!10* #.? ,30=!1#8!F#1!3.0:

781,36;, +ZJ' ?#1#B#0(0 43$ 1,(0( 361%3)( =#$#)(1($0#$( 8(00 $(#?!82 #/#!8#B8( #.? 606#882 8(00 $(8!#B8( 1,#.)3$1#8!12 ?#1#B#0(0* 1,( 8!)!1(? ?#1# #/#!8#B8( !.?!%#1( 1,#1)3$B!?!12 ?6( 13 +ZJ' !.%$(#0(0 Y!1, #;(_^W_]: "3$B!?!124$3) +ZJ' )#2 B( #44(%1(? B2 31,($ %3)3$B!? %,$3.!%%3.?!1!3.0 ̀ (:;:* %#$?!3/#0%68#$ ?!0(#0(* )60%6830R(8(1#8

!)=#!$)(.1* ?!#B(1(0 )(88!160a 1,#1 #$( $(8#1(? 13 +ZJ'#.? )#2 ,#/( #. !)=#%1 3. 1,( =#1!(.1E0 ,(#81, 01#160* #0Y(88 #0 !.1($4($( Y!1, +ZJ' )#.#;()(.1:

2GJDLPCDQ

H,( D3$8? <(#81, Z$;#.!F#1!3. =6B8!0,(0 )3$1#8!12 01#1!01!%043$ 0(8(%1(? %#60(0 34 ?(#1, #..6#882 43$ #88 D<Z $(;!3.0g#??!1!3.#8 !.43$)#1!3. !0 #/#!8#B8( 4$3) 1,( WHO EvidenceKGJ -HLPDN 3GPCMQ .HULJDBHED `:442V``NNNON:0O+%4` "$+8"%/"a: '#1# )601 B( !.1($=$(1(? %#61!36082* ,3Y(/($*B(%#60( 34 !.%3.0!01(.1 60( 34 1($)!.383;2 43$ +ZJ': G.1,( _^1, $(/!0!3. 34 1,( G+'* ?(#1,0 4$3) +ZJ' 3$ %,$3.!%#!$Y#20 3B01$6%1!3. #$( !.%86?(? !. 1,( B$3#? %#1(;3$2 34d+ZJ' #.? #88!(? %3.?!1!3.0e `G+'W_^ %3?(0 Ac]Wcma:

-.?($W$(%3;.!1!3. #.? 6.?($W?!#;.30!0 34 +ZJ' 01!88#44(%1 1,( #%%6$#%2 34 )3$1#8!12 ?#1#_c*_i: 781,36;, +ZJ'!0 341(. # =$!)#$2 %#60( 34 ?(#1,* !1 !0 )3$( 8!R(82 13 B(8!01(? #0 # %3.1$!B613$2 %#60( 34 ?(#1, 3$ 3)!11(? 4$3)

the death certicate entirely_m*i^c: <3Y(/($* !1 !0 %8(#$1,#1 +ZJ' !0 3.( 34 1,( )301 !)=3$1#.1 %#60(0 34 ?(#1,!. )301 %36.1$!(0: H,( 983B#8 @6$?(. 34 '!0(#0( I16?2=$3\(%1(? 1,#1 +ZJ'* Y,!%, $#.R(? 0!M1, #0 # %#60( 34?(#1, !. _ll^* Y!88 B(%3)( 1,( 1,!$? 8(#?!.; %#60( 34 ?(#1,Y3$8?Y!?( B2 ]^]^g # .(Y($ =$3\(%1!3. (01!)#1(? +ZJ'Y!88 B( 1,( 436$1, 8(#?!.; %#60( 34 ?(#1, !. ]^b^i: H,!0!.%$(#0(? )3$1#8!12 !0 )#!.82 ?$!/(. B2 1,( (M=#.?!.;(=!?()!% 34 0)3R!.;* $(?6%(? )3$1#8!12 4$3) 31,($ %3))3.%#60(0 34 ?(#1, `(:;: !0%,()!% ,(#$1 ?!0(#0(* !.4(%1!360?!0(#0(0a* #.? #;!.; 34 1,( Y3$8? =3=68#1!3.:

*MGEGBCM $@JOHE

COPD is associated with signicant economic burden. In1,( L6$3=(#. -.!3.* 1,( 131#8 ?!$(%1 %3010 34 $(0=!$#13$2?!0(#0( #$( (01!)#1(? 13 B( #B361 mu 34 1,( 131#8 ,(#81,%#$( B6?;(1* Y!1, +ZJ' #%%36.1!.; 43$ imu `bo:m B!88!3.L6$30a 34 1,!0 %301 34 $(0=!$#13$2 ?!0(#0(_n: G. 1,( -.!1(?I1#1(0 1,( (01!)#1(? ?!$(%1 %3010 34 +ZJ' #$( v]l:i B!88!3.#.? 1,( !.?!$(%1 %3010 v]^:c B!88!3._o: +ZJ' (M#%($B#1!3.0#%%36.1 43$ 1,( ;$(#1(01 =$3=3$1!3. 34 1,( 131#8 +ZJ'B6$?(. 3. 1,( ,(#81, %#$( 0201(): Q31 06$=$!0!.;82* 1,($( !0# 01$!R!.; ?!$(%1 $(8#1!3.0,!= B(1Y((. 1,( 0(/($!12 34 +ZJ'#.? 1,( %301 34 %#$(* #.? 1,( ?!01$!B61!3. 34 %3010 %,#.;(0#0 1,( ?!0(#0( =$3;$(00(0: K3$ (M#)=8(* ,30=!1#8!F#1!3.

#.? #)B68#13$2 3M2;(. %3010 03#$ #0 +ZJ' 0(/($!12!.%$(#0(0: 7.2 (01!)#1( 34 ?!$(%1 )(?!%#8 (M=(.?!16$(0 43$,3)( %#$( 6.?($W$(=$(0(.10 1,( 1$6( %301 34 ,3)( %#$( 1303%!(12* B(%#60( !1 !;.3$(0 1,( (%3.3)!% /#86( 34 1,( %#$(=$3/!?(? 13 1,30( Y!1, +ZJ' B2 4#)!82 )()B($0:

G. ?(/(83=!.; %36.1$!(0* ?!$(%1 )(?!%#8 %3010 )#2 B( 8(00!)=3$1#.1 1,#. 1,( !)=#%1 34 +ZJ' 3. Y3$R=8#%( #.?,3)( =$3?6%1!/!12: @(%#60( 1,( ,(#81, %#$( 0(%13$ )!;,1.31 =$3/!?( 83.;W1($) 06==3$1!/( %#$( 0($/!%(0 43$ 0(/($(82

8/16/2019 GOLD Report 2016


c BKJIPIGILP <PB LEK@EIKF

?!0#B8(? !.?!/!?6#80* +ZJ' )#2 43$%( 1Y3 !.?!/!?6#80 138(#/( 1,( Y3$R=8#%(q1,( #44(%1(? !.?!/!?6#8 #.? # 4#)!82)()B($ Y,3 )601 .3Y 01#2 ,3)( 13 %#$( 43$ 1,( ?!0#B8(?$(8#1!/(: I!.%( ,6)#. %#=!1#8 !0 341(. 1,( )301 !)=3$1#.1.#1!3.#8 #00(1 43$ ?(/(83=!.; %36.1$!(0* 1,( !.?!$(%1 %3010 34+ZJ' )#2 $(=$(0(.1 # 0($!360 1,$(#1 13 1,(!$ (%3.3)!(0:

'GMCLP $@JOHE

I!.%( )3$1#8!12 344($0 # 8!)!1(? =($0=(%1!/( 3. 1,( ,6)#.burden of a disease, it is desirable to nd other measures34 ?!0(#0( B6$?(. 1,#1 #$( %3.0!01(.1 #.? )(#06$#B8(#%$300 .#1!3.0: H,( #61,3$0 34 1,( 983B#8 @6$?(. 34'!0(#0( I16?2 ?(0!;.(? # )(1,3? 13 (01!)#1( 1,( 4$#%1!3.34 )3$1#8!12 #.? ?!0#B!8!12 #11$!B61#B8( 13 )#\3$ ?!0(#0(0#.? !.\6$!(0 60!.; # %3)=30!1( )(#06$( 34 1,( B6$?(.34 (#%, ,(#81, =$3B8()* 1,( '!0#B!8!12W7?\601(? 5!4( [(#$`'75[a]*_l*]^. The DALYs for a specic condition are the06) 34 2(#$0 8301 B(%#60( 34 =$()#16$( )3$1#8!12 #.?2(#$0 34 8!4( 8!/(? Y!1, ?!0#B!8!12* #?\601(? 43$ 1,( 0(/($!12 34

?!0#B!8!12: G. _ll^* +ZJ' Y#0 1,( 1Y(841, 8(#?!.; %#60( 34'75[0 8301 !. 1,( Y3$8?* $(0=3.0!B8( 43$ ]:_u 34 1,( 131#8:

7%%3$?!.; 13 1,( =$3\(%1!3.0* +ZJ' Y!88 B( 1,( 0(/(.1,8(#?!.; %#60( 34 '75[0 8301 Y3$8?Y!?( !. ]^b^i:

781,36;, %!;#$(11( 0)3R!.; !0 1,( B(01W016?!(? +ZJ'

$!0R 4#%13$* !1 !0 .31 1,( 3.82 3.( #.? 1,($( !0 %3.0!01(.1(/!?(.%( 4$3) (=!?()!383;!% 016?!(0 1,#1 .3.0)3R($0may also develop chronic airow limitation]_W]c: "6%, 341,( (/!?(.%( %3.%($.!.; $!0R 4#%13$0 43$ +ZJ' %3)(04$3) %$300W0(%1!3.#8 (=!?()!383;!%#8 016?!(0 1,#1 !?(.1!42#003%!#1!3.0 $#1,($ 1,#. %#60(W#.?W(44(%1 $(8#1!3.0,!=0:

781,36;, 0(/($#8 83.;!16?!.#8 016?!(0 34 +ZJ' ,#/(43883Y(? ;$36=0 #.? =3=68#1!3.0 43$ 6= 13 ]^ 2(#$0]i* .3.(,#0 )3.!13$(? 1,( =$3;$(00!3. 34 1,( ?!0(#0( 1,$36;, !10(.1!$( %36$0(* 3$ ,#0 !.%86?(? 1,( =$(W#.? =($!.#1#8 =($!3?0Y,!%, )#2 B( !)=3$1#.1 !. 0,#=!.; #. !.?!/!?6#8E0 4616$(+ZJ' $!0R: H,60* %6$$(.1 6.?($01#.?!.; 34 $!0R 4#%13$0 43$+ZJ' !0 !. )#.2 $(0=(%10 01!88 !.%3)=8(1(:

+ZJ' $(06810 4$3) # ;(.(W(./!$3.)(.1 !.1($#%1!3.: 7)3.;=(3=8( Y!1, 1,( 0#)( 0)3R!.; ,!013$2* .31 #88 Y!88 ?(/(83=+ZJ' ?6( 13 ?!44($(.%(0 !. ;(.(1!% =$(?!0=30!1!3. 13 1,(?!0(#0(* 3$ !. ,3Y 83.; 1,(2 8!/(: C!0R 4#%13$0 43$ +ZJ')#2 #803 B( $(8#1(? !. )3$( %3)=8(M Y#20: K3$ (M#)=8(*gender may inuence whether a person takes up smoking3$ (M=($!(.%(0 %($1#!. 3%%6=#1!3.#8 3$ (./!$3.)(.1#8(M=306$(0g 03%!3(%3.3)!% 01#160 )#2 B( 8!.R(? 13 # %,!8?E0B!$1, Y(!;,1 `#0 !1 !)=#%10 3. 86.; ;$3Y1, #.? ?(/(83=)(.1

#.? !. 16$. 3. 060%(=1!B!8!12 13 ?(/(83= 1,( ?!0(#0(ag#.? 83.;($ 8!4( (M=(%1#.%2 Y!88 #883Y ;$(#1($ 8!4(1!)((M=306$( 13 $!0R 4#%13$0: -.?($01#.?!.; 1,( $(8#1!3.0,!=0#.? !.1($#%1!3.0 #)3.; $!0R 4#%13$0 $(f6!$(0 46$1,($!./(01!;#1!3.:

!HEHI

H,( ;(.(1!% $!0R 4#%13$ 1,#1 !0 B(01 ?3%6)(.1(? !0 # 0(/($(hereditary deciency of alpha-1 antitrypsin]m* # )#\3$%!$%68#1!.; !.,!B!13$ 34 0($!.( =$31(#0(0: 781,36;, #8=,#W_antitrypsin deciency is relevant to only a small part of theY3$8?E0 =3=68#1!3.* !1 !88601$#1(0 1,( !.1($#%1!3. B(1Y((.;(.(0 #.? (./!$3.)(.1#8 (M=306$(0 8(#?!.; 13 +ZJ':

A signicant familial risk of airow limitation hasB((. 3B0($/(? !. 0)3R!.; 0!B8!.;0 34 =#1!(.10 Y!1,0(/($( +ZJ']n* 06;;(01!.; 1,#1 ;(.(1!% 13;(1,($ Y!1,environmental factors could inuence this susceptibility.I!.;8( ;(.(0 06%, #0 1,( ;(.( (.%3?!.; )#1$!M

)(1#883=$31(!.#0( _] `33?W[ a ,#/( B((. $(8#1(? 13?(%8!.( !. 86.; 46.%1!3.]o: 781,36;, 0(/($#8 ;(.3)(WY!?( #003%!#1!3. 016?!(0 !.?!%#1( # $38( 34 1,( ;(.( 43$1,( #8=,#W.!%31!.!% #%(128%,38!.( $(%(=13$ #0 Y(88 #0 1,(,(?;(W,3; !.1($#%1!.; =$31(!. ;(.( #.? =300!B82 3.( 3$ 1Y3others, there remains a discrepancy between ndings from#.#820(0 34 +ZJ' #.? 86.; 46.%1!3. #0 Y(88 #0 B(1Y((.;(.3)(WY!?( #003%!#1!3. 016?2 #.#820(0 #.? %#.?!?#1(;(.( #.#820(0]lWbb:

%FH LEO !HEOHJ

7;( !0 341(. 8!01(? #0 # $!0R 4#%13$ 43$ +ZJ': G1 !0 6.%8(#$ !4

healthy aging as such leads to COPD or if age reects the06) 34 %6)68#1!/( (M=306$(0 1,$36;,361 8!4(: G. 1,( =#01*)301 016?!(0 0,3Y(? 1,#1 +ZJ' =$(/#8(.%( #.? )3$1#8!12Y($( ;$(#1($ #)3.; )(. 1,#. Y3)(. B61 ?#1# 4$3)?(/(83=(? %36.1$!(0_o*bc 0,3Y 1,#1 1,( =$(/#8(.%( 34 1,(?!0(#0( !0 .3Y #8)301 (f6#8 !. )(. #.? Y3)(.* =$3B#B82reecting the changing patterns of tobacco smoking.I3)( 016?!(0 ,#/( (/(. 06;;(01(? 1,#1 Y3)(. #$( )3$(060%(=1!B8( 13 1,( (44(%10 34 13B#%%3 0)3R( 1,#. )(.biWbo:

Lung Growth and Development

56.; ;$3Y1, !0 $(8#1(? 13 =$3%(00(0 3%%6$$!.; ?6$!.;;(01#1!3.* B!$1,* #.? (M=306$(0 ?6$!.; %,!8?,33? #.?#?38(0%(.%(bl*c^: C(?6%(? )#M!)#8 #11#!.(? 86.; 46.%1!3.`#0 )(#06$(? B2 0=!$3)(1$2a )#2 !?(.1!42 !.?!/!?6#80 Y,3#$( #1 !.%$(#0(? $!0R 43$ 1,( ?(/(83=)(.1 34 +ZJ'c_:

7.2 4#%13$ 1,#1 #44(%10 86.; ;$3Y1, ?6$!.; ;(01#1!3. #.?%,!8?,33? ,#0 1,( =31(.1!#8 43$ !.%$(#0!.; #. !.?!/!?6#8E0$!0R 34 ?(/(83=!.; +ZJ': K3$ (M#)=8(* # 8#$;( 016?2 #.?meta-analysis conrmed a positive association betweenB!$1, Y(!;,1 #.? KLN

_ !. #?681,33?c]* #.? 0(/($#8 016?!(0

,#/( 436.? #. (44(%1 34 (#$82 %,!8?,33? 86.; !.4(%1!3.0:

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8/16/2019 GOLD Report 2016


BKJIPIGILP <PB LEK@EIKF i

7 016?2 436.? 1,#1 4#%13$0 !. (#$82 8!4( 1($)(? d%,!8?,33??!0#?/#.1#;( 4#%13$0e Y($( #0 !)=3$1#.1 #0 ,(#/2 0)3R!.;!. =$(?!%1!.; 86.; 46.%1!3. !. (#$82 #?681 8!4(cb:

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7%$300 1,( Y3$8?* %!;#$(11( 0)3R!.; !0 1,( )301 %3))3.82(.%36.1($(? $!0R 4#%13$ 43$ +ZJ': +!;#$(11( 0)3R($0,#/( # ,!;,($ =$(/#8(.%( 34 $(0=!$#13$2 02)=13)0 #.?86.; 46.%1!3. #B.3$)#8!1!(0* # ;$(#1($ #..6#8 $#1( 34?(%8!.( !. KLN

_* #.? # ;$(#1($ +ZJ' )3$1#8!12 $#1( 1,#.

.3.0)3R($0cc: Z1,($ 12=(0 34 13B#%%3 ̀ (:;:* =!=(* %!;#$*Y#1($ =!=(ci*m_ca #.? )#$!\6#.#cm #$( #803 $!0R 4#%13$0 43$+ZJ'cn*co: J#00!/( (M=306$( 13 %!;#$(11( 0)3R( `#803R.3Y. #0 (./!$3.)(.1#8 13B#%%3 0)3R( 3$ LHIa )#2#803 %3.1$!B61( 13 $(0=!$#13$2 02)=13)0cl #.? +ZJ'i^ B2!.%$(#0!.; 1,( 86.;E0 131#8 B6$?(. 34 !.,#8(? =#$1!%8(0 #.?;#0(0i_*i]: I)3R!.; ?6$!.; =$(;.#.%2 )#2 #803 =30( # $!0R43$ 1,( 4(160* B2 #44(%1!.; 86.; ;$3Y1, #.? ?(/(83=)(.1 !.61($3 #.? =300!B82 1,( =$!)!.; 34 1,( !))6.( 0201()ib*ic:

Z%%6=#1!3.#8 (M=306$(0* !.%86?!.; 3$;#.!% #.?!.3$;#.!% ?6010 #.? %,()!%#8 #;(.10 #.? 46)(0* #$( #.6.?($#==$(%!#1(? $!0R 4#%13$ 43$ +ZJ'iiWin: 7. #.#820!034 1,( 8#$;( -:I: =3=68#1!3.WB#0(? Q<7QLI GGG 06$/(234 #8)301 _^*^^^ #?6810 #;(? b^Wni 2(#$0 (01!)#1(? 1,(4$#%1!3. 34 +ZJ' #11$!B61#B8( 13 Y3$R Y#0 _l:]u 3/($#88*#.? b_:_u #)3.; .(/($W0)3R($0io: H,(0( (01!)#1(0 #$(%3.0!01(.1 Y!1, # 01#1()(.1 =6B8!0,(? B2 1,( 7)($!%#.H,3$#%!% I3%!(12 1,#1 %3.%86?(? 1,#1 3%%6=#1!3.#8(M=306$(0 #%%36.1 43$ _^W]^u 34 (!1,($ 02)=13)0 3$46.%1!3.#8 !)=#!$)(.1 %3.0!01(.1 Y!1, +ZJ'il: H,( $!0R4$3) 3%%6=#1!3.#8 (M=306$(0 !. 8(00 $(;68#1(? #$(#0 34 1,(Y3$8? !0 8!R(82 13 B( )6%, ,!;,($ 1,#. $(=3$1(? !. 016?!(0

4$3) L6$3=( #.? Q3$1, 7)($!%#:

D33?* #.!)#8 ?6.;* %$3= $(0!?6(0* #.? %3#8* 12=!%#882burned in open res or poorly functioning stoves, may8(#? 13 /($2 ,!;, 8(/(80 34 !.?33$ #!$ =38861!3.: L/!?(.%(%3.1!.6(0 13 ;$3Y 1,#1 !.?33$ =38861!3. 4$3) B!3)#00%33R!.; #.? ,(#1!.; !. =33$82 /(.1!8#1(? ?Y(88!.;0 !0 #.!)=3$1#.1 $!0R 4#%13$ 43$ +ZJ'm^Wmm*m_i: 78)301 b B!88!3.=(3=8( Y3$8?Y!?( 60( B!3)#00 #.? %3#8 #0 1,(!$ )#!.036$%( 34 (.($;2 43$ %33R!.;* ,(#1!.;* #.? 31,($ ,360(,38?.((?0* 03 1,( =3=68#1!3. #1 $!0R Y3$8?Y!?( !0 /($2 8#$;(mb*mn:

<!;, 8(/(80 34 6$B#. #!$ =38861!3. #$( ,#$)468 13 !.?!/!?6#80

Y!1, (M!01!.; ,(#$1 3$ 86.; ?!0(#0(: H,( $38( 34 361?33$#!$ =38861!3. !. %#60!.; +ZJ' !0 6.%8(#$* B61 #==(#$0 13B( 0)#88 Y,(. %3)=#$(? Y!1, 1,#1 34 %!;#$(11( 0)3R!.;:It has also been difcult to assess the effects of single=38861#.10 !. 83.;W1($) (M=306$( 13 #1)30=,($!% =38861!3.:<3Y(/($* #!$ =38861!3. 4$3) 4300!8 46(8 %3)B601!3.* =$!)#$!824$3) )313$ /(,!%8( ()!00!3.0 !. %!1!(0* !0 #003%!#1(? Y!1,?(%$()(.10 34 $(0=!$#13$2 46.%1!3.mo: H,( $(8#1!/( (44(%10 340,3$1W1($)* ,!;,W=(#R (M=306$(0 #.? 83.;W1($)* 83YW8(/(8(M=306$(0 #$( 2(1 13 B( $(038/(?:

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J3/($12 !0 %8(#$82 # $!0R 4#%13$ 43$ +ZJ' B61 1,(%3)=3.(.10 34 =3/($12 1,#1 %3.1$!B61( 13 1,!0 #$( 6.%8(#$:H,($( !0 01$3.; (/!?(.%( 1,#1 1,( $!0R 34 ?(/(83=!.; +ZJ'!0 !./($0(82 $(8#1(? 13 03%!3(%3.3)!% 01#160ml: G1 !0 .31clear, however, whether this pattern reects exposures

13 !.?33$ #.? 361?33$ #!$ =38861#.10* %$3Y?!.;* =33$.61$!1!3.* !.4(%1!3.0* 3$ 31,($ 4#%13$0 1,#1 #$( $(8#1(? 13 83Y03%!3(%3.3)!% 01#160:

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701,)# )#2 B( # $!0R 4#%13$ 43$ 1,( ?(/(83=)(.1 34 +ZJ'*#81,36;, 1,( (/!?(.%( !0 .31 %3.%860!/(: G. # $(=3$1 4$3)# 83.;!16?!.#8 %3,3$1 34 1,( H6%03. L=!?()!383;!%#8 I16?234 7!$Y#2 ZB01$6%1!/( '!0(#0(* #?6810 Y!1, #01,)# Y($(436.? 13 ,#/( # 1Y(8/(W438? ,!;,($ $!0R 34 #%f6!$!.; +ZJ'3/($ 1!)( 1,#. 1,30( Y!1,361 #01,)#* #41($ #?\601!.; 43$0)3R!.;n^: 7.31,($ 83.;!16?!.#8 016?2 34 =(3=8( Y!1,

#01,)# 436.? 1,#1 #$36.? ]^u 34 06B\(%10 ?(/(83=(?irreversible airow limitation and reduced transfercoefcientn_* #.? !. # 83.;!16?!.#8 016?2 0(84W$(=3$1(?#01,)# Y#0 #003%!#1(? Y!1, (M%(00 8300 34 KLN

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1,( ;(.($#8 =3=68#1!3.n]: G. 1,( L6$3=(#. +3))6.!12C(0=!$#13$2 <(#81, I6$/(2* B$3.%,!#8 ,2=($$(0=3.0!/(.(00Y#0 0(%3.? 3.82 13 %!;#$(11( 0)3R!.; #0 1,( 8(#?!.; $!0R4#%13$ 43$ +ZJ'* $(0=3.0!B8( 43$ _iu 34 1,( =3=68#1!3.#11$!B61#B8( $!0R `0)3R!.; ,#? # =3=68#1!3. #11$!B61#B8($!0R 34 bluanb. The pathology of chronic airow limitation!. #01,)#1!% .3.0)3R($0 #.? .3.W#01,)#1!% 0)3R($0 !0)#$R(?82 ?!44($(.1* 06;;(01!.; 1,#1 1,( 1Y3 ?!0(#0( (.1!1!(0)#2 $()#!. ?!44($(.1 (/(. Y,(. =$(0(.1!.; Y!1, 0!)!8#$82

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G. 1,( 0()!.#8 016?2 B2 K8(1%,($ #.? %3Y3$R($0* %,$3.!%B$3.%,!1!0 Y#0 .31 #003%!#1(? Y!1, ?(%8!.( !. 86.;46.%1!3.nn: <3Y(/($* 06B0(f6(.1 016?!(0 ,#/( 436.? #.#003%!#1!3. B(1Y((. )6%60 ,2=($0(%$(1!3. #.? KLN_ ?(%8!.(no* #.? %36;, #.? 0=616) =$3?6%1!3. !0 #003%!#1(?Y!1, !.%$(#0(? )3$1#8!12 !. )!8? 13 )3?($#1( +ZJ'm_m:G. 236.;($ #?6810 Y,3 0)3R( 1,( =$(0(.%( 34 %,$3.!%B$3.%,!1!0 !0 #003%!#1(? Y!1, #. !.%$(#0(? 8!R(8!,33? 34?(/(83=!.; +ZJ'nl*o^:

8/16/2019 GOLD Report 2016


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7 ,!013$2 34 0(/($( %,!8?,33? $(0=!$#13$2 !.4(%1!3. ,#0B((. #003%!#1(? Y!1, $(?6%(? 86.; 46.%1!3. #.? !.%$(#0(?$(0=!$#13$2 02)=13)0 !. #?681,33?bl*nb: I60%(=1!B!8!12 13!.4(%1!3.0 =8#20 # $38( !. (M#%($B#1!3.0 34 +ZJ' B61 1,((44(%1 3. 1,( ?(/(83=)(.1 34 1,( ?!0(#0( !0 8(00 %8(#$:

<GN !.4(%1!3. ,#0 B((. 0,3Y. 13 #%%(8($#1( 1,( 3.0(134 0)3R!.;W$(8#1(? ()=,20()#o_: H6B($%6830!0 ,#0B((. 436.? 13 B( # $!0R 4#%13$ 43$ +ZJ'o]*ob: G. #??!1!3.*16B($%6830!0 !0 B31, # ?!44($(.1!#8 ?!#;.30!0 13 +ZJ' #.? #=31(.1!#8 %3)3$B!?!12ob*oc:G.,#8(? %!;#$(11( 0)3R( #.? 31,($ .3M!360 =#$1!%8(0 06%,as smoke from biomass fuels cause lung inammation,a normal response that appears to be modied in

patients who develop COPD. This chronic inammatory$(0=3.0( )#2 !.?6%( =#$(.%,2)#8 1!006( ?(01$6%1!3.`$(0681!.; !. ()=,20()#a* #.? ?!0$6=1 .3$)#8 $(=#!$ #.?defense mechanisms (resulting in small airway brosis).H,(0( =#1,383;!%#8 %,#.;(0 8(#? 13 #!$ 1$#==!.; #.?progressive airow limitation. A brief overview follows34 1,( =#1,383;!% %,#.;(0 !. +ZJ'* 1,(!$ %(8868#$ #.?)38(%68#$ )(%,#.!0)0* #.? ,3Y 1,(0( 6.?($8!( =,20!383;!%#B.3$)#8!1!(0 #.? 02)=13)0 %,#$#%1($!01!% 34 1,( ?!0(#0(oi

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J#1,383;!%#8 %,#.;(0 %,#$#%1($!01!% 34 +ZJ' #$(436.? !. 1,( #!$Y#20* 86.; =#$(.%,2)#* #.? =68)3.#$2

/#0%68#16$(om: H,( =#1,383;!%#8 %,#.;(0 !.%86?( %,$3.!%inammation, with increased numbers of specicinammatory cell types in different parts of the lung, and01$6%16$#8 %,#.;(0 $(0681!.; 4$3) $(=(#1(? !.\6$2 #.? $(=#!$:In general, the inammatory and structural changes in1,( #!$Y#20 !.%$(#0( Y!1, ?!0(#0( 0(/($!12 #.? =($0!01 3.0)3R!.; %(00#1!3.:

3LDNGFHEHICI

The inammation in the respiratory tract of COPD patientsappears to be a modication of the inammatory response34 1,( $(0=!$#13$2 1$#%1 13 %,$3.!% !$$!1#.10 06%, #0 %!;#$(11(smoke. The mechanisms for this amplied inammation#$( .31 2(1 6.?($0133? B61 )#2 B( ;(.(1!%#882 ?(1($)!.(?:J#1!(.10 %#. %8(#$82 ?(/(83= +ZJ' Y!1,361 0)3R!.;* B61the nature of the inammatory response in these patients is6.R.3Y.: ZM!?#1!/( 01$(00 #.? #. (M%(00 34 =$31(!.#0(0 !.the lung further modify lung inammation. Together, these)(%,#.!0)0 8(#? 13 1,( %,#$#%1($!01!% =#1,383;!%#8 %,#.;(0in COPD. Lung inammation persists after smoking%(00#1!3. 1,$36;, 6.R.3Y. )(%,#.!0)0* #81,36;,#613#.1!;(.0 #.? =($0!01(.1 )!%$33$;#.!0)0 )#2 =8#2 #$38(on:

'-./01.23 4153667 ZM!?#1!/( 01$(00 )#2 B( #. !)=3$1#.1#)=8!42!.; )(%,#.!0) !. +ZJ'oo: @!3)#$R($0 34 3M!?#1!/(01$(00 `(:;:* ,2?$3;(. =($3M!?(* oW!03=$301#.(a #$(!.%$(#0(? !. 1,( (M,#8(? B$(#1, %3.?(.0#1(* 0=616)* #.?0201()!% %!$%68#1!3. 34 +ZJ' =#1!(.10: ZM!?#1!/( 01$(00 !046$1,($ !.%$(#0(? !. (M#%($B#1!3.0: ZM!?#.10 #$( ;(.($#1(?B2 %!;#$(11( 0)3R( #.? 31,($ !.,#8(? =#$1!%68#1(0* #.?released from activated inammatory cells such as)#%$3=,#;(0 #.? .(61$3=,!80: H,($( )#2 #803 B( #$(?6%1!3. !. (.?3;(.360 #.1!3M!?#.10 !. +ZJ' =#1!(.10 #0# $(0681 34 $(?6%1!3. !. # 1$#.0%$!=1!3. 4#%13$ %#88(? Q$4] 1,#1$(;68#1(0 )#.2 #.1!3M!?#.1 ;(.(0ol:

85913063:);1.<5913063 $=>0?0;@37 H,($( !0 %3)=(88!.;(/!?(.%( 43$ #. !)B#8#.%( !. 1,( 86.;0 34 +ZJ' =#1!(.10B(1Y((. =$31(#0(0 1,#1 B$(#R ?3Y. %3..(%1!/( 1!006(%3)=3.(.10 #.? #.1!=$31(#0(0 1,#1 =$31(%1 #;#!.01 1,!0:Several proteases, derived from inammatory cells and(=!1,(8!#8 %(880* #$( !.%$(#0(? !. +ZJ' =#1!(.10: H,($(

!0 !.%$(#0!.; (/!?(.%( 1,#1 1,(2 )#2 !.1($#%1 Y!1, (#%,31,($: J$31(#0(W)(?!#1(? ?(01$6%1!3. 34 (8#01!.* # )#\3$%3..(%1!/( 1!006( %3)=3.(.1 !. 86.; =#$(.%,2)#* !0B(8!(/(? 13 B( #. !)=3$1#.1 4(#16$( 34 ()=,20()# #.? !08!R(82 13 B( !$$(/($0!B8(: Inammatory Cells. COPD is characterized by a specicpattern of inammation involving increased numbers of+'ow ̀ %21313M!%a H%_ 82)=,3%21(0 =$(0(.1 3.82 !. 0)3R($01,#1 ?(/(83= 1,( ?!0(#0(oi: H,(0( %(880* 13;(1,($ Y!1,neutrophils and macrophages, release inammatory)(?!#13$0 #.? (.F2)(0 #.? !.1($#%1 Y!1, 01$6%16$#8%(880 !. 1,( #!$Y#20* 86.; =#$(.%,2)# #.? =68)3.#$2

/#0%68#16$(l^

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Inammatory Mediators. The wide variety of inammatory)(?!#13$0 1,#1 ,#/( B((. 0,3Y. 13 B( !.%$(#0(? !. +ZJ'=#1!(.10l_ attract inammatory cells from the circulation(chemotactic factors), amplify the inammatory process(proinammatory cytokines), and induce structural changes`;$3Y1, 4#%13$0al]:

Differences in Inammation Between COPD and Asthma. 781,36;, B31, +ZJ' #.? #01,)# #$( #003%!#1(? Y!1,chronic inammation of the respiratory tract, there aredifferences in the inammatory cells and mediators involved!. 1,( 1Y3 ?!0(#0(0* Y,!%, !. 16$. #%%36.1 43$ ?!44($(.%(0 !.=,20!383;!%#8 (44(%10* 02)=13)0* #.? $(0=3.0( 13 1,($#=2nc

I3)( =#1!(.10 Y!1, +ZJ' ,#/( 4(#16$(0 %3.0!01(.1 Y!1,asthma and may have a mixed inammatory pattern with!.%$(#0(? (30!.3=,!80:

3LDNGUNQICGPGFQ

H,($( !0 .3Y # ;33? 6.?($01#.?!.; 34 ,3Y 1,( 6.?($82!.;?!0(#0( =$3%(00 !. +ZJ' 8(#?0 13 1,( %,#$#%1($!01!%

3%(-#"#!+1 3%(-#!*0*'/'

%0. 3%(-#3-+'/#"#!+

8/16/2019 GOLD Report 2016


BKJIPIGILP <PB LEK@EIKF n

=,20!383;!% #B.3$)#8!1!(0 #.? 02)=13)0: K3$ (M#)=8(*inammation and narrowing of peripheral airways leads13 ?(%$(#0(? KLN

_: J#$(.%,2)#8 ?(01$6%1!3. ?6( 13

emphysema also contributes to airow limitation and leads13 ?(%$(#0(? ;#0 1$#.04($:

Airow Limitation and Air Trapping. H,( (M1(.1 34inammation, brosis, and luminal exudates in small#!$Y#20 !0 %3$$(8#1(? Y!1, 1,( $(?6%1!3. !. KLN

_ #.?

KLN_hKN+ $#1!3* #.? =$3B#B82 Y!1, 1,( #%%(8($#1(? ?(%8!.(

!. KLN_ %,#$#%1($!01!% 34 +ZJ'l^: H,!0 =($!=,($#8 #!$Y#2

3B01$6%1!3. =$3;$(00!/(82 1$#=0 #!$ ?6$!.; (M=!$#1!3.*resulting in hyperination. Although emphysema is more#003%!#1(? Y!1, ;#0 (M%,#.;( #B.3$)#8!1!(0 1,#. Y!1,$(?6%(? KLN

_* !1 ?3(0 %3.1$!B61( 13 ;#0 1$#==!.; ?6$!.;

(M=!$#1!3.: H,!0 !0 (0=(%!#882 03 #0 #8/(38#$ #11#%,)(.1013 0)#88 #!$Y#20 #$( ?(01$32(? Y,(. 1,( ?!0(#0( B(%3)(0more severe. Hyperination reduces inspiratory capacity06%, 1,#1 46.%1!3.#8 $(0!?6#8 %#=#%!12 !.%$(#0(0* =#$1!%68#$82during exercise (dynamic hyperination), resulting in

!.%$(#0(? ?20=.(# #.? 8!)!1#1!3. 34 (M($%!0( %#=#%!12:H,(0( 4#%13$0 %3.1$!B61( 13 !)=#!$)(.1 34 1,( !.1$!.0!%%3.1$#%1!8( =$3=($1!(0 34 $(0=!$#13$2 )60%8(0g 1,!0 $(06810in upregulation of local pro-inammatory cytokines. It isthought that hyperination develops early in the disease#.? !0 1,( )#!. )(%,#.!0) 43$ (M($1!3.#8 ?20=.(#lb*lc:@$3.%,3?!8#13$0 #%1!.; 3. =($!=,($#8 #!$Y#20 $(?6%( #!$1$#==!.;* 1,($(B2 $(?6%!.; 86.; /386)(0 #.? !)=$3/!.;02)=13)0 #.? (M($%!0( %#=#%!12lb:

Gas Exchange Abnormalities. 9#0 (M%,#.;(#B.3$)#8!1!(0 $(0681 !. ,2=3M()!# #.? ,2=($%#=.!#*#.? ,#/( 0(/($#8 )(%,#.!0)0 !. +ZJ': G. ;(.($#8*

;#0 1$#.04($ 43$ 3M2;(. #.? %#$B3. ?!3M!?( Y3$0(.0 #01,( ?!0(#0( =$3;$(00(0: C(?6%(? /(.1!8#1!3. )#2 #803B( ?6( 13 $(?6%(? /(.1!8#13$2 ?$!/(: H,!0 )#2 8(#? 13%#$B3. ?!3M!?( $(1(.1!3. Y,(. !1 !0 %3)B!.(? Y!1, $(?6%(?/(.1!8#1!3. ?6( 13 # ,!;, Y3$R 34 B$(#1,!.; B(%#60(of severe obstruction and hyperination coupled with/(.1!8#13$2 )60%8( !)=#!$)(.1: H,( #B.3$)#8!1!(0 !.#8/(38#$ /(.1!8#1!3. #.? # $(?6%(? =68)3.#$2 /#0%68#$ B(?46$1,($ Y3$0(. 1,( N

7hk #B.3$)#8!1!(0li:

Mucus Hypersecretion. "6%60 ,2=($0(%$(1!3.* $(0681!.;!. # %,$3.!% =$3?6%1!/( %36;,* !0 # 4(#16$( 34 %,$3.!%bronchitis and is not necessarily associated with airow8!)!1#1!3.: +3./($0(82* .31 #88 =#1!(.10 Y!1, +ZJ' ,#/(02)=13)#1!% )6%60 ,2=($0(%$(1!3.: D,(. =$(0(.1* !1 !0?6( 13 #. !.%$(#0(? .6)B($ 34 ;3B8(1 %(880 #.? (.8#$;(?06B)6%30#8 ;8#.?0 !. $(0=3.0( 13 %,$3.!% #!$Y#2 !$$!1#1!3.B2 %!;#$(11( 0)3R( #.? 31,($ .3M!360 #;(.10: I(/($#8)(?!#13$0 #.? =$31(#0(0 01!)68#1( )6%60 ,2=($0(%$(1!3.#.? )#.2 34 1,() (M($1 1,(!$ (44(%10 1,$36;, 1,( #%1!/#1!3.34 (=!?($)#8 ;$3Y1, 4#%13$ $(%(=13$ `L9KCalm:

Pulmonary Hypertension. J68)3.#$2 ,2=($1(.0!3. )#2?(/(83= 8#1( !. 1,( %36$0( 34 +ZJ' #.? !0 ?6( )#!.8213 ,2=3M!% /#03%3.01$!%1!3. 34 0)#88 =68)3.#$2 #$1($!(0*(/(.16#882 $(0681!.; !. 01$6%16$#8 %,#.;(0 1,#1 !.%86?(!.1!)#8 ,2=($=8#0!# #.? 8#1($ 0)331, )60%8( ,2=($1$3=,2h,2=($=8#0!#ln. There is an inammatory response in/(00(80 0!)!8#$ 13 1,#1 0((. !. 1,( #!$Y#20 #.? (/!?(.%(34 (.?31,(8!#8 %(88 ?2046.%1!3.: H,( 8300 34 1,( =68)3.#$2%#=!88#$2 B(? !. ()=,20()# )#2 #803 %3.1$!B61(13 !.%$(#0(? =$(006$( !. 1,( =68)3.#$2 %!$%68#1!3.:J$3;$(00!/( =68)3.#$2 ,2=($1(.0!3. )#2 8(#? 13 $!;,1/(.1$!%68#$ ,2=($1$3=,2 #.? (/(.16#882 13 $!;,1W0!?( %#$?!#%4#!86$(:

"-0@35>01.9;67 LM#%($B#1!3.0 34 $(0=!$#13$2 02)=13)0341(. 3%%6$ !. =#1!(.10 Y!1, +ZJ'* 1$!;;($(? B2 !.4(%1!3.Y!1, B#%1($!# 3$ /!$60(0 `Y,!%, )#2 %3(M!01a* (./!$3.)(.1#8=38861#.10* 3$ 6.R.3Y. 4#%13$0: J#1!(.10 Y!1, B#%1($!#8#.? /!$#8 (=!03?(0 ,#/( # %,#$#%1($!01!% $(0=3.0( Y!1,increased inammation. During respiratory exacerbations

there is increased hyperination and gas trapping, withreduced expiratory ow, thus accounting for the increased?20=.(#lo: H,($( !0 #803 Y3$0(.!.; 34 N

7hk #B.3$)#8!1!(0*

Y,!%, %#. $(0681 !. ,2=3M()!#ll: Z1,($ %3.?!1!3.0`=.(6)3.!#* 1,$3)B3()B38!0)* #.? #%61( %#$?!#% 4#!86$(a)#2 )!)!% 3$ #;;$#/#1( #. (M#%($B#1!3. 34 +ZJ':

Systemic Features. G1 !0 !.%$(#0!.;82 $(%3;.!F(? 1,#1 )#.2=#1!(.10 Y!1, +ZJ' ,#/( %3)3$B!?!1!(0 1,#1 ,#/( # )#\3$!)=#%1 3. f6#8!12 34 8!4( #.? 06$/!/#8_^^. Airow limitationand particularly hyperination affect cardiac function and;#0 (M%,#.;(_^_. Inammatory mediators in the circulation)#2 %3.1$!B61( 13 0R(8(1#8 )60%8( Y#01!.; #.? %#%,(M!#*

#.? )#2 !.!1!#1( 3$ Y3$0(. %3)3$B!?!1!(0 06%, #0 !0%,()!%,(#$1 ?!0(#0(* ,(#$1 4#!86$(* 301(3=3$30!0* .3$)3%21!%#.()!#* ?!#B(1(0* )(1#B38!% 02.?$3)(* #.? ?(=$(00!3.:

8/16/2019 GOLD Report 2016


8/16/2019 GOLD Report 2016


5-%3(*)

8

!$)A%'4$4

)%! ASSESSMENT

8/16/2019 GOLD Report 2016


_^ BI<=PL1I1 <PB <11K113KPG

]*+ 3#/0('Y

• 7 %8!.!%#8 ?!#;.30!0 34 +ZJ' 0,368? B( %3.0!?($(?!. #.2 =#1!(.1 Y,3 ,#0 ?20=.(#* %,$3.!% %36;, 3$0=616) =$3?6%1!3.* #.? # ,!013$2 34 (M=306$( 13 $!0R4#%13$0 43$ 1,( ?!0(#0(:

• I=!$3)(1$2 !0 $(f6!$(? 13 )#R( 1,( ?!#;.30!0 !. 1,!0%8!.!%#8 %3.1(M1g 1,( =$(0(.%( 34 # =301WB$3.%,3?!8#13$KLN

_/FVC < 0.70 conrms the presence of persistent

airow limitation and thus of COPD.

• H,( ;3#80 34 +ZJ' #00(00)(.1 #$( 13 ?(1($)!.(1,( 0(/($!12 34 1,( ?!0(#0(* !.%86?!.; 1,( 0(/($!12of airow limitation, the impact on the patient’s

,(#81, 01#160* #.? 1,( $!0R 34 4616$( (/(.10 `06%, #0(M#%($B#1!3.0* ,30=!1#8 #?)!00!3.0* 3$ ?(#1,a* !.

3$?($ 13 ;6!?( 1,($#=2:• +3)3$B!?!1!(0 3%%6$ 4$(f6(.182 !. +ZJ' =#1!(.10*

!.%86?!.; %#$?!3/#0%68#$ ?!0(#0(* 0R(8(1#8 )60%8(?2046.%1!3.* )(1#B38!% 02.?$3)(* 301(3=3$30!0*?(=$(00!3.* #.? 86.; %#.%($: 9!/(. 1,#1 1,(2 %#.3%%6$ !. =#1!(.10 Y!1, )!8?* )3?($#1( #.? 0(/($(airow limitation and inuence mortality and

,30=!1#8!F#1!3.0 !.?(=(.?(.182* %3)3$B!?!1!(0 0,368?B( #%1!/(82 833R(? 43$* #.? 1$(#1(? #==$3=$!#1(82 !4=$(0(.1:

• Q3.W06$;!%#8 B$3.%,30%3=!% 86.; /386)( $(?6%1!3.1(%,.!f6(0 0,368? .31 B( 60(? 3610!?( %8!.!%#8 1$!#806.1!8 )3$( ?#1# #$( #/#!8#B8(:

./%!0#'/'

7 %8!.!%#8 ?!#;.30!0 34 +ZJ' 0,368? B( %3.0!?($(? !.#.2 =#1!(.1 Y,3 ,#0 ?20=.(#* %,$3.!% %36;, 3$ 0=616)=$3?6%1!3.* #.? # ,!013$2 34 (M=306$( 13 $!0R 4#%13$0 43$ 1,(?!0(#0( `(LAPH 8S:a: I=!$3)(1$2 !0 $(f6!$(? 13 )#R( 1,(?!#;.30!0 !. 1,!0 %8!.!%#8 %3.1(M1i^ig 1,( =$(0(.%( 34 # =301WB$3.%,3?!8#13$ KLN

_/FVC < 0.70 conrms the presence of

persistent airow limitation and thus of COPD.

The spirometric criterion for airow limitation remains apost-bronchodilator xed ratio of FEV

_hKN+ x ̂ :n^: H,!0

%$!1($!3. !0 0!)=8(* !.?(=(.?(.1 34 $(4($(.%( /#86(0*#.? ,#0 B((. 60(? !. .6)($360 %8!.!%#8 1$!#80 43$)!.;1,( (/!?(.%( B#0( 4$3) Y,!%, )301 34 36$ 1$(#1)(.1$(%3))(.?#1!3.0 #$( ?$#Y.: '!#;.301!% 0!)=8!%!12 #.?%3.0!01(.%2 #$( R(2 43$ 1,( B602 .3.W0=(%!#8!01 %8!.!%!#.:

D,!8( =301WB$3.%,3?!8#13$ 0=!$3)(1$2 !0 $(f6!$(? 43$ 1,(

?!#;.30!0 #.? #00(00)(.1 34 0(/($!12 34 +ZJ'* 1,( ?(;$((of reversibility of airow limitation (e.g., measuring FEV

_

B(43$( #.? #41($ B$3.%,3?!8#13$ 3$ %3$1!%301($3!?0a !0 .383.;($ $(%3))(.?(?i^m: H,( ?(;$(( 34 $(/($0!B!8!12 ,#0

.(/($ B((. 0,3Y. 13 #?? 13 1,( ?!#;.30!0* ?!44($(.1!#8

?!#;.30!0 Y!1, #01,)#* 3$ 13 =$(?!%1!.; 1,( $(0=3.0( 1383.;W1($) 1$(#1)(.1 Y!1, B$3.%,3?!8#13$0 3$ %3$1!%301($3!?0:H,( $38( 34 0%$((.!.; 0=!$3)(1$2 !. 1,( ;(.($#8 =3=68#1!3.!0 %3.1$3/($0!#8: @31, KLN

_ #.? KN+ =$(?!%1 #88W%#60(

)3$1#8!12 !.?(=(.?(.1 34 13B#%%3 0)3R!.;* #.? #B.3$)#8lung function identies a subgroup of smokers at increased

$!0R 43$ 86.; %#.%($: H,!0 ,#0 B((. 1,( B#0!0 34 #.#$;6)(.1 1,#1 0%$((.!.; 0=!$3)(1$2 0,368? B( ()=832(?#0 # ;83B#8 ,(#81, #00(00)(.1 1338_^]*_^b: <3Y(/($*1,($( #$( .3 ?#1# 13 !.?!%#1( 1,#1 0%$((.!.; 0=!$3)(1$2!0 (44(%1!/( !. ?!$(%1!.; )#.#;()(.1 ?(%!0!3.0 3$ !.improving COPD outcomes in patients who are identied

before the development of signicant symptoms_^c: H,60*

GOLD advocates active case ndingioc B61 .31 0%$((.!.;0=!$3)(1$2:

The use of the xed FEV_/FVC ratio to dene airow

8!)!1#1!3. Y!88 $(0681 !. )3$( 4$(f6(.1 ?!#;.30!0 34 +ZJ' !.1,( (8?($82_^i* #.? 8(00 4$(f6(.1 ?!#;.30!0 !. #?6810 236.;($1,#. ci 2(#$0_^m* (0=(%!#882 34 )!8? ?!0(#0(* %3)=#$(? 1360!.; # %61344 B#0(? 3. 1,( 83Y($ 8!)!1 34 .3$)#8 `55Qa/#86(0 43$ KLN

_hKN+: H,(0( 55Q /#86(0 #$( B#0(? 3.

5-%3(*) 8Y ./%!0#'/' %0. %''*''2*0(

(LAPH 8S:S ]HQ /EOCMLDGJI KGJ

5GEICOHJCEF L .CLFEGICI GK 5#3.

!"#$%&'( !*+,- .#& /'(0"(1 $/%("1'2(3- %0 .#3 "0 24'$' %#&%5.2"($ .(' /('$'#2

%# .# %#&%6%&7.8 "6'( .9' :;< =4'$' %#&%5.2"($ .(' #"2 &%.9#"$2%5 24'1$'86'$- >72

24' /('$'#5' "0 1782%/8' ?'3 %#&%5.2"($ %#5('.$'$ 24' /(">.>%8%23 "0 . &%.9#"$%$ "0

!*+,< @/%("1'2(3 %$ ('A7%('& 2" '$2.>8%$4 . &%.9#"$%$ "0 !*+,<

.QIUEHL DNLD CI: K)'=)*$$#B* P;')$*6$ 'B*) 2#-*R<

Characteristically worse with exercise. K*)$#$2*62<

5NJGECM MG@FNY T3A 9* #62*)-#22*62 365 -3A 9* (64)'5(%2#B*<

5NJGECM IU@D@B UJGO@MDCGEY

L6A 4322*)6 ', %7)'6#% $4(2(- 4)'5(%2#'6 -3A #65#%32* 1/K"<

-CIDGJQ GK HWUGI@JH DG JCI_ KLMDGJIY

>'93%%' $-'Y* P#6%&(5#6= 4'4(&3) &'%3& 4)*43)32#'6$R<

@-'Y* ,)'- 7'-* %''Y#6= 365 7*32#6= ,(*&$<

/%%(432#'63& 5($2$ 365 %7*-#%3&$<

,LBCPQ NCIDGJQ GK 5#3.

8/16/2019 GOLD Report 2016


BI<=PL1I1 <PB <11K113KPG __

1,( .3$)#8 ?!01$!B61!3. #.? %8#00!42 1,( B3113) iu 34the healthy population as abnormal. From a scientic

perspective it is difcult to determine which of these criteria

!0 %3$$(%1 13 ?!#;.30( +ZJ'_^n* #.? .3 016?!(0 (M!01%3)=#$!.; %8!.!%#8 ?!#;.30!0 B#0(? 3. 1,( 1Y3 #==$3#%,(0:<3Y(/($* 55Q /#86(0 #$( ,!;,82 ?(=(.?(.1 3. 1,( %,3!%( 34

/#8!? $(4($(.%( (f6#1!3.0 60!.; =301WB$3.%,3?!8#13$ KLN_*#.? .(!1,($ 83.;!16?!.#8 016?!(0 /#8!?#1!.; 1,( 60( 34 1,(55Q .3$ 016?!(0 60!.; $(4($(.%( (f6#1!3.0 !. =3=68#1!3.0Y,($( 0)3R!.; !0 .31 1,( )#\3$ %#60( 34 +ZJ' #$(#/#!8#B8(: H,( $!0R 34 )!0?!#;.30!0 #.? 3/($W1$(#1)(.1of individual patients using the xed ratio as a diagnostic

%$!1($!3. !0 8!)!1(?* #0 0=!$3)(1$2 !0 3.82 3.( =#$#)(1($43$ (01#B8!0,!.; 1,( %8!.!%#8 ?!#;.30!0 34 +ZJ'* 1,( 31,($0B(!.; 02)=13)0 #.? $!0R 4#%13$0:

'QBUDGBI

H,( %,#$#%1($!01!% 02)=13)0 34 +ZJ' #$( %,$3.!% #.?

=$3;$(00!/( ?20=.(#* %36;,* #.? 0=616) =$3?6%1!3. 1,#1%#. B( /#$!#B8( 4$3) ?#2W13W?#2i^n*i^o: +,$3.!% %36;, #.?sputum production may precede the development of airow

8!)!1#1!3. B2 )#.2 2(#$0: G.?!/!?6#80* =#$1!%68#$82 1,30((M=30(? 13 +ZJ' $!0R 4#%13$0* Y,3 =$(0(.1 Y!1, 1,(0(02)=13)0 0,368? B( (M#)!.(? 13 0(#$%, 43$ #. 6.?($82!.;%#60(`0a #.? #==$3=$!#1( !.1($/(.1!3.0 1#R(.: +3./($0(82*signicant airow limitation may develop without chronic

cough and sputum production. Although COPD is dened

on the basis of airow limitation, in practice the decision

13 0((R )(?!%#8 ,(8= `#.? 03 =($)!1 1,( ?!#;.30!0 13 B()#?(a !0 606#882 ?(1($)!.(? B2 1,( !)=#%1 34 # 02)=13) 3.# =#1!(.1E0 ?#!82 8!4(: 7 =($03. )#2 0((R )(?!%#8 #11(.1!3.

either because of chronic symptoms or because of a rst(M#%($B#1!3.:

Dyspnea: '20=.(#* # %#$?!.#8 02)=13) 34 +ZJ'* !0 #)#\3$ %#60( 34 ?!0#B!8!12 #.? #.M!(12 #003%!#1(? Y!1, 1,(?!0(#0(: H2=!%#8 +ZJ' =#1!(.10 ?(0%$!B( 1,(!$ ?20=.(##0 # 0(.0( 34 !.%$(#0(? (443$1 13 B$(#1,(* ,(#/!.(00* #!$,6.;($* 3$ ;#0=!.;_^o: <3Y(/($* 1,( 1($)0 60(? 13 ?(0%$!B(?20=.(# /#$2 B31, B2 !.?!/!?6#8 #.? B2 %6816$(_^l:

Cough. Chronic cough, often the rst symptom of COPD

13 ?(/(83=__^* !0 4$(f6(.182 ?!0%36.1(? B2 1,( =#1!(.1 #0 #.(M=(%1(? %3.0(f6(.%( 34 0)3R!.; #.?h3$ (./!$3.)(.1#8(M=306$(0: G.!1!#882* 1,( %36;, )#2 B( !.1($)!11(.1* B618#1($ !0 =$(0(.1 (/($2 ?#2* 341(. 1,$36;,361 1,( ?#2: H,(%,$3.!% %36;, !. +ZJ' )#2 B( 6.=$3?6%1!/(___: G. 03)(cases, signicant airow limitation may develop without

1,( =$(0(.%( 34 # %36;,: (LAPH 8S8 8!010 03)( 34 1,( 31,($%#60(0 34 %,$3.!% %36;,:

Sputum production. +ZJ' =#1!(.10 %3))3.82 $#!0(0)#88 f6#.1!1!(0 34 1(.#%!360 0=616) #41($ %36;,!.; B3610:

C(;68#$ =$3?6%1!3. 34 0=616) 43$ b 3$ )3$( )3.1,0 !. ]%3.0(%61!/( 2(#$0 `!. 1,( #B0(.%( 34 #.2 31,($ %3.?!1!3.0that may explain it) is the epidemiological denition of

%,$3.!% B$3.%,!1!0__]* B61 1,!0 !0 # 03)(Y,#1 #$B!1$#$2denition that does not reect the range of sputum

=$3?6%1!3. !. +ZJ' =#1!(.10: I=616) =$3?6%1!3. !0 341(.

difcult to evaluate because patients may swallow sputumrather than expectorate it, a habit subject to signicant

%6816$#8 #.? ;(.?($ /#$!#1!3.: J#1!(.10 =$3?6%!.; 8#$;(/386)(0 34 0=616) )#2 ,#/( 6.?($82!.; B$3.%,!(%1#0!0:The presence of purulent sputum reects an increase

in inammatory mediators__b* #.? !10 ?(/(83=)(.1 )#2!?(.1!42 1,( 3.0(1 34 # B#%1($!#8 (M#%($B#1!3.__c:

Wheezing and Chest Tightness: D,((F!.; #.? %,(01tightness are nonspecic symptoms that may vary between

?#20* #.? 3/($ 1,( %36$0( 34 # 0!.;8( ?#2: 76?!B8(Y,((F( )#2 #$!0( #1 # 8#$2.;(#8 8(/(8 #.? .((? .31 B(#%%3)=#.!(? B2 #60%681#13$2 #B.3$)#8!1!(0: 781($.#1!/(82*Y!?(0=$(#? !.0=!$#13$2 3$ (M=!$#13$2 Y,((F(0 %#. B(=$(0(.1 3. 8!01(.!.; 13 1,( %,(01: +,(01 1!;,1.(00 341(.43883Y0 (M($1!3.* !0 =33$82 83%#8!F(?* !0 )60%68#$ !.%,#$#%1($* #.? )#2 #$!0( 4$3) !03)(1$!% %3.1$#%1!3. 34 1,(!.1($%301#8 )60%8(0: 7. #B0(.%( 34 Y,((F!.; 3$ %,(011!;,1.(00 ?3(0 .31 (M%86?( # ?!#;.30!0 34 +ZJ'* .3$ ?3(0the presence of these sypmtoms conrm a diagnosis of#01,)#:

Additional Features in Severe Disease. K#1!;6(* Y(!;,1

8300 #.? #.3$(M!# #$( %3))3. =$3B8()0 !. =#1!(.10 Y!1,0(/($( #.? /($2 0(/($( +ZJ'__i: H,(2 #$( =$3;.301!%#882!)=3$1#.1__m #.? %#. #803 B( # 0!;. 34 31,($ ?!0(#0(0 `(:;:*16B($%6830!0* 86.; %#.%($a* #.? 1,($(43$( 0,368? #8Y#20B( !./(01!;#1(?: +36;, 02.%3=( 3%%6$0 ?6( 13 $#=!?!.%$(#0(0 !. !.1$#1,3$#%!% =$(006$( ?6$!.; =$383.;(? #11#%R034 %36;,!.;: +36;,!.; 0=(880 )#2 #803 %#60( $!B 4$#%16$(0*Y,!%, #$( 03)(1!)(0 #02)=13)#1!%: 7.R8( 0Y(88!.; )#2B( 1,( 3.82 02)=13)#1!% =3!.1($ 13 1,( ?(/(83=)(.1 34 %3$=68)3.#8(: I2)=13)0 34 ?(=$(00!3. #.?h3$ #.M!(12 )($!1

(LAPH 8S8S 5L@IHI GK 5NJGECM 5G@FN

/EDJLDNGJLMCM

• !4("#%5 ">$2(752%6' /781"#.(3 &%$'.$'

• B$241.

• C7#9 5.#5'(

• =7>'(578"$%$

• D("#54%'52.$%$

• C'02 4'.(2 0.%87('

•

E#2'($2%2%.8 87#9 &%$'.$'• Cystic brosis

• E&%"/.24%5 5"794

*WDJLDNGJLMCM

• !4("#%5 .88'(9%5 (4%#%2%$

• F//'( B%(G.3 !"794 @3#&("1' HFB!@I

• Gastroesophageal reux

• J'&%5.2%"# H'<9<- B!K %#4%>%2"($I

8/16/2019 GOLD Report 2016


_] BI<=PL1I1 <PB <11K113KPG

specic enquiry in the clinical history because they are%3))3. !. +ZJ'__n #.? #$( #003%!#1(? Y!1, !.%$(#0(? $!0R34 (M#%($B#1!3.0 #.? =33$($ ,(#81, 01#160:

2HOCMLP -CIDGJQ

7 ?(1#!8(? )(?!%#8 ,!013$2 34 # .(Y =#1!(.1 R.3Y. 3$

1,36;,1 13 ,#/( +ZJ' 0,368? #00(00j

• ?-4+"%4d9 "H209#." 40 .+9M Q-/40.9* 06%, #0 0)3R!.; #.?3%%6=#1!3.#8 3$ (./!$3.)(.1#8 (M=306$(0

• ?-94 ,"8+/-) :+940.A * !.%86?!.; #01,)#* #88($;2* 0!.60!1!0*3$ .#0#8 =382=0g $(0=!$#13$2 !.4(%1!3.0 !. %,!8?,33?g31,($ $(0=!$#13$2 ?!0(#0(0

• J-,+)A :+940.A 0Q 7L?B 0. 04:". /:.0%+/ ."92+.-40.A 8+9"-9"

• ?-44".% 0Q 9A,240, 8"$")02,"%4 j +ZJ' 12=!%#882?(/(83=0 !. #?681 8!4( #.? )301 =#1!(.10 #$( %3.0%!36034 !.%$(#0(? B$(#1,8(00.(00* )3$( 4$(f6(.1 3$=$383.;(? dY!.1($ %38?0*e #.? 03)( 03%!#8 $(01$!%1!3. 43$# .6)B($ 34 2(#$0 B(43$( 0((R!.; )(?!%#8 ,(8=

• S+940.A 0Q "H-/".6-4+0%9 0. 2."$+0#9 :092+4-)+>-4+0%9 Q0.."92+.-40.A 8+90.8".V J#1!(.10 )#2 B( #Y#$( 34 =($!3?!%Y3$0(.!.; 34 02)=13)0 (/(. !4 1,(0( (=!03?(0 ,#/(not been identied as exacerbations of COPD

• ?."9"%/" 0Q /0,0.6+8+4+"0* 06%, #0 ,(#$1 ?!0(#0(*301(3=3$30!0* )60%6830R(8(1#8 ?!03$?($0* #.?)#8!;.#.%!(0 1,#1 )#2 #803 %3.1$!B61( 13 $(01$!%1!3. 34#%1!/!12__o

• I,2-/4 0Q 8+9"-9" 0% 2-4+"%4d9 )+Q"* !.%86?!.; 8!)!1#1!3. 34#%1!/!12* )!00(? Y3$R #.? (%3.3)!% !)=#%1* (44(%1 3.4#)!82 $361!.(0* 4((8!.;0 34 ?(=$(00!3. 3$ #.M!(12* Y(88B(!.; #.? 0(M6#8 #%1!/!12

• 10/+-) -%8 Q-,+)A 9#220.4 -$-+)-6)" 40 4:" 2-4+"%4

• ?099+6+)+4+"9 Q0. ."8#/+%* .+9M Q-/40.9& "92"/+-))A 9,0M+%*/"99-4+0%

3NQICMLP *WLBCELDCGE

781,36;, #. !)=3$1#.1 =#$1 34 =#1!(.1 %#$(* # =,20!%#8(M#)!.#1!3. !0 $#$(82 ?!#;.301!% !. +ZJ': J,20!%#8 0!;.0of airow limitation are usually not present until signicant!)=#!$)(.1 34 86.; 46.%1!3. ,#0 3%%6$$(?__l*_]^* #.? 1,(!$detection has a relatively low sensitivity and specicity. A.6)B($ 34 =,20!%#8 0!;.0 )#2 B( =$(0(.1 !. +ZJ'* B611,(!$ #B0(.%( ?3(0 .31 (M%86?( 1,( ?!#;.30!0:

'UCJGBHDJQ

I=!$3)(1$2 !0 1,( )301 $(=$3?6%!B8( #.? 3B\(%1!/(measurement of airow limitation available. Peak

expiratory ow measurement alone cannot be reliably used

#0 1,( 3.82 ?!#;.301!% 1(01* ?(0=!1( !10 ;33? 0(.0!1!/!12*because of its weak specicity_]_: 933? f6#8!12 0=!$3)(1$!%)(#06$()(.1 !0 =300!B8( !. #.2 ,(#81, %#$( 0(11!.; #.? #88,(#81, %#$( Y3$R($0 Y,3 %#$( 43$ +ZJ' =#1!(.10 0,368?

,#/( #%%(00 13 0=!$3)(1$2: (LAPH 8ST 06))#$!F(0 03)( 341,( 4#%13$0 .((?(? 13 #%,!(/( #%%6$#1( 1(01 $(06810:

I=!$3)(1$2 0,368? )(#06$( 1,( /386)( 34 #!$ 43$%!B82(M,#8(? 4$3) 1,( =3!.1 34 )#M!)#8 !.0=!$#1!3. `43$%(?/!1#8 %#=#%!12* KN+a #.? 1,( /386)( 34 #!$ (M,#8(? ?6$!.;

the rst second of this maneuver (forced expiratory/386)( !. 3.( 0(%3.?* KLN_a* #.? 1,( $#1!3 34 1,(0( 1Y3

)(#06$()(.10 ̀ KLN_hKN+a 0,368? B( %#8%68#1(?: H,( $#1!3

B(1Y((. KLN_ #.? 083Y /!1#8 %#=#%!12 `N+a* KLN

_hN+* !0

03)(1!)(0 )(#06$(? !.01(#? 34 1,( KLN_hKN+ $#1!3: H,!0

Y!88 341(. 8(#? 13 83Y($ /#86(0 34 1,( $#1!3* (0=(%!#882 !.pronounced airow limitation; however, the cut-off point of

^:n 0,368? 01!88 B( #==8!(?: I=!$3)(1$2 )(#06$()(.10 #$((/#86#1(? B2 %3)=#$!03. Y!1, $(4($(.%( /#86(0_]] B#0(? 3.#;(* ,(!;,1* 0(M* #.? $#%(:

,CF@JH 8S:% 0,3Y0 # .3$)#8 0=!$3)(1$2 1$#%!.;g ,CF@JH

8S:$ # 0=!$3)(1$2 1$#%!.; 12=!%#8 34 # =#1!(.1 Y!1,3B01$6%1!/( ?!0(#0(: J#1!(.10 Y!1, +ZJ' 12=!%#882 0,3Y #?(%$(#0( !. B31, KLN

_ #.? KN+:

H,( ;3#80 34 +ZJ' #00(00)(.1 #$( 13 ?(1($)!.( 1,( 0(/($!12

34 1,( ?!0(#0(* !10 !)=#%1 3. 1,( =#1!(.1E0 ,(#81, 01#160 #.?

1,( $!0R 34 4616$( (/(.10 `06%, #0 (M#%($B#1!3.0* ,30=!1#8

(LAPH 8STS 5GEICOHJLDCGEI CE 3HJKGJBCEF 'UCJGBHDJQ

3JHULJLDCGE• @4#)'-*2*)$ 6**5 %3&#9)32#'6 '6 3 )*=(&3) 93$#$<

• @4#)'-*2*)$ $7'(&5 4)'5(%* 73)5 %'4A ') 73B* 3 5#=#23& 5#$4&3A ', 27*

expiratory curve to permit detection of technical errors or have an automatic4)'-42 2' #5*62#,A 36 (6$32#$,3%2')A 2*$2 365 27* )*3$'6 ,') #2<

• >7* $(4*)B#$') ', 27* 2*$2 6**5$ 2)3#6#6= #6 #2$ *,,*%2#B* 4*),')-36%*<

• Maximal patient effort in performing the test is required to avoid(65*)*$2#-32#'6 ', B3&(*$ 365 7*6%* *))')$ #6 5#3=6'$#$ 365 -363=*-*62<

$JGEMNGOCPLDCGE

• K'$$#9&* 5'$3=* 4)'2'%'&$ 3)* HJJ -%= 9*23ED3='6#$2: IUJ -%= 362#%7'&#6*)=#%:

') 27* 2;' %'-9#6*5IEE. FEVI $7'(&5 9* -*3$()*5 IJDIF -#6(2*$ 3,2*) 3

$7')2D3%2#6= 9*23ED3='6#$2 #$ =#B*6: ') MJDHF -#6(2*$ 3,2*) 3 $7')2D3%2#6=

362#%7'&#6*)=#% ') 3 %'-9#632#'6<

3HJKGJBLEMH

• Spirometry should be performed using techniques that meet published$23653)5$IEM<

• The expiratory volume/time traces should be smooth and free from irregularities.• >7* )*%')5#6= $7'(&5 =' '6 &'6= *6'(=7 ,') 3 B'&(-* 4&32*3( 2' 9* )*3%7*5:

;7#%7 -3A 23Y* -')* 2736 IF $*%'65$ #6 $*B*)* 5#$*3$*<

• Both FVC and FEVI $7'(&5 9* 27* &3)=*$2 B3&(* '923#6*5 ,)'- 36A ', M

technically satisfactory curves and the FVC and FEVI B3&(*$ #6 27*$* 27)**

%()B*$ $7'(&5 B3)A 9A 6' -')* 2736 F\ ') IFJ -&: ;7#%7*B*) #$ =)*32*)<

• The FEVI/FVC ratio should be taken from the technically acceptable curve with

the largest sum of FVC and FEVI<

Evaluation

• @4#)'-*2)A -*3$()*-*62$ 3)* *B3&(32*5 9A %'-43)#$'6 ', 27* )*$(&2$ ;#27

appropriate reference values based on age, height, sex, and race.• The presence of a postbronchodilator FEV

I/FVC < 0.70 conrms the presence

of airow limitation.

%''*''2*0( #, ./'*%'*

8/16/2019 GOLD Report 2016


BI<=PL1I1 <PB <11K113KPG _b

#?)!00!3.0 3$ ?(#1,a* !. 3$?($ 13* (/(.16#882* ;6!?( 1,($#=2:

H3 #%,!(/( 1,(0( ;3#80* +ZJ' #00(00)(.1 )601 %3.0!?($1,( 43883Y!.; #0=(%10 34 1,( ?!0(#0( 0(=#$#1(82j

• +6$$(.1 8(/(8 34 =#1!(.1E0 02)=13)0• I(/($!12 34 1,( 0=!$3)(1$!% #B.3$)#8!12• LM#%($B#1!3. $!0R• J$(0(.%( 34 %3)3$B!?!1!(0

%IIHIIBHED GK 'QBUDGBI

G. 1,( =#01* +ZJ' Y#0 /!(Y(? #0 # ?!0(#0( 8#$;(82%,#$#%1($!F(? B2 B$(#1,8(00.(00: 7 0!)=8( )(#06$(of breathlessness such as the Modied British Medical

C(0(#$%, +36.%!8 `)"C+a k6(01!3..#!$( `(LAPH 8SVa Y#0%3.0!?($(? #?(f6#1( 43$ #00(00)(.1 34 02)=13)0* #0 1,()"C+ $(8#1(0 Y(88 13 31,($ )(#06$(0 34 ,(#81, 01#160l_

#.? =$(?!%10 4616$( )3$1#8!12 $!0Rl]: <3Y(/($* !1 !0 .3Y$(%3;.!F(? 1,#1 +ZJ' ,#0 )681!=8( 02)=13)#1!% (44(%10_i_:K3$ 1,!0 $(#03.* # %3)=$(,(.0!/( 02)=13) #00(00)(.1 !0$(%3))(.?(? $#1,($ 1,#. \601 # )(#06$( 34 B$(#1,8(00.(00:

The most comprehensive disease-specic health-related

f6#8!12 34 8!4( 3$ ,(#81, 01#160 f6(01!3..#!$(0 06%, #0 1,(+Ck]bm #.? I9Ckbcn #$( 133 %3)=8(M 13 60( !. $361!.(=$#%1!%(* B61 1Y3 0,3$1($ %3)=$(,(.0!/( )(#06$(0 `+ZJ'

700(00)(.1 H(01* +7H #.? +ZJ' +3.1$38 k6(01!3..#!$(*++ka ,#/( B((. ?(/(83=(? #.? #$( 06!1#B8(:

COPD Assessment Test (CAT). H,( +ZJ' 700(00)(.1H(01 !0 #. oW!1() 6.!?!)(.0!3.#8 )(#06$( 34 ,(#81, 01#160!)=#!$)(.1 !. +ZJ'_]c: G1 Y#0 ?(/(83=(? 13 B( #==8!%#B8(Y3$8?Y!?( #.? /#8!?#1(? 1$#.08#1!3.0 #$( #/#!8#B8( !. # Y!?($#.;( 34 8#.;6#;(0: H,( 0%3$( $#.;(0 4$3) ^Wc^* %3$$(8#1(0/($2 %830(82 Y!1, 1,( I9Ck* #.? ,#0 B((. (M1(.0!/(82?3%6)(.1(? !. .6)($360 =6B8!%#1!3.0ico `,11=jhhYYY:%#1(013.8!.(:3$;a:

COPD Control Questionnaire (CCQ). H,( +ZJ' +3.1$38

k6(01!3..#!$( !0 # _^ !1() 0(84W#?)!.!01($(? f6(01!3..#!$(?(/(83=(? 13 )(#06$( %8!.!%#8 %3.1$38 !. =#1!(.10 Y!1,+ZJ'i^l* i_^: 781,36;, 1,( %3.%(=1 34 d%3.1$38e !. +ZJ'$()#!.0 %3.1$3/($0!#8* 1,( ++k !0 0,3$1 #.? (#02 13#?)!.!01($: G1 !0 $(8!#B8( #.? $(0=3.0!/(* !0 #/#!8#B8( !. #$#.;( 34 8#.;6#;(0* #.? ,#0 B((. /#8!?#1(? `,11=jhhYYY:%%f:.8a: 7 )!.!)#882 %8!.!%#8 !)=3$1#.1 ?!44($(.%(0 `"+G'a ?6$!.;rehabilitation of -0.4 for the CCQ has been identiedm_n:

5NGCMH GK 5@D 3GCEDI

H,( +7H #.? ++k =$3/!?( # )(#06$( 34 1,( 02)=13)#1!%!)=#%1 34 +ZJ' B61 ?3 .31 %#1(;3$!F( =#1!(.10 !.13 83Y($#.? ,!;,($ 02)=13)0 43$ 1,( =6$=30( 34 1$(#1)(.1: H,(I9Ck !0 1,( )301 Y!?(82 ?3%6)(.1(? %3)=$(,(.0!/()(#06$(g 0%3$(0 8(00 1,#. ]i #$( 6.%3))3. !. ?!#;.30(?+ZJ' =#1!(.10_b_*icl and scores ≥ 25 are very uncommon

! " # $ % &

!

"

#

$

! " # $ % & ' # ) * & + ,

-)%&' ,&."/0,

%

!

12!3 4 56

1!7 4 86

12!3 91!7 4 :;< ! " # $ % & '

# ) * & + ,

-)%&' ,&."/0,

%

$

#

"

!

! " # $ % &

12!3 4 3;<6

1!7 4 =;>6

12!3 91!7 4 :;8?

@A,*+$.*)B&

1)C$+& >;3D; EF)+"%&*+G H @A,*+$.*)B& I),&J,&1)C$+& >;3K; EF)+"%&*+G H L"+%J# -+J.&

Table 2.4. Modied Medical Research

5G@EMCP a@HIDCGEELCJH KGJ %IIHIICEF

the Severity of Breathlessness

3"*%'* (/5] /0 (-* $#X (-%( %33"/*' (# +#6

7#0* $#X #0"+<

mMRC Grade 0. I only get breathless with strenuous exercise. □

-TC1 .)35* I< Q =*2 $7')2 ', 9)*327 ;7*6 7())A#6= '6 27* &*B*& □

') ;3&Y#6= (4 3 $&#=72 7#&&<

-TC1 .)35* E< Q ;3&Y $&';*) 2736 4*'4&* ', 27* $3-* 3=* '6 27* □&*B*& 9*%3($* ', 9)*327&*$$6*$$: ') Q 73B* 2' $2'4 ,') 9)*327 ;7*6

;3&Y#6= '6 -A ';6 43%* '6 27* &*B*&<

-TC1 .)35* M< Q $2'4 ,') 9)*327 3,2*) ;3&Y#6= 39'(2 IJJ -*2*)$ ') □3,2*) 3 ,*; -#6(2*$ '6 27* &*B*&<

-TC1 .)35* H< Q 3- 2'' 9)*327&*$$ 2' &*3B* 27* 7'($* ') Q 3- □9)*327&*$$ ;7*6 5)*$$#6= ') (65)*$$#6=<

8/16/2019 GOLD Report 2016


_c BI<=PL1I1 <PB <11K113KPG

!. ,(#81,2 =($03.0icl: G. %8!.!%#8 1$!#80 34 83.;W#%1!.;B$3.%,3?!8#13$ )(?!%#1!3.0 ]^_*]_^* i_m* ii^Wiib* 1,( B#0(8!.(Y(!;,1(? )(#. I9Ck 0%3$( Y#0 cc* #.? 3.( 01#.?#$??(/!#1!3. B(83Y 1,( )(#. Y#0 ]m: H,($(43$(* !1 !0$(%3))(.?(? 1,#1 # 02)=13) 0%3$( (f6!/#8(.1 13 I9Ckscore ≥ 25 should be used as the cut-point for considering

$(;68#$ 1$(#1)(.1 43$ 02)=13)0 !.%86?!.; B$(#1,8(00.(00*=#$1!%68#$82 0!.%( 1,!0 %3$$(0=3.?0 13 1,( $#.;( 34 0(/($!120((. !. =#1!(.10 $(%$6!1(? 13 1,( 1$!#80 1,#1 =$3/!?( 1,((/!?(.%( B#0( 43$ 1$(#1)(.1 $(%3))(.?#1!3.0: H,((f6!/#8(.1 %61W=3!.1 43$ 1,( +7H !0 _^_]b* iic: H,( (f6!/#8(.1cut-point for the CCQ has yet to be nally determined, but

#==(#$0 13 B( !. 1,( $#.;( _:^ W _:i:

7. (f6!/#8(.1 )"C+ 0%3$( %#..31 B( %#8%68#1(? B(%#60(# 0!)=8( B$(#1,8(00.(00 %61W=3!.1 %#..31 (f6#1( 13 #%3)=$(,(.0!/( 02)=13) 0%3$( %61W=3!.1: H,( ;$(#1)#\3$!12 34 =#1!(.10 Y!1, #. I9Ck 34 ]i 3$ )3$( Y!88,#/( #. )"C+ 34 ] 3$ )3$(g ,3Y(/($ =#1!(.10 Y!1,)"C+ x ] )#2 #803 ,#/( # .6)B($ 34 31,($ +ZJ'symptoms. While use of an mMRC ≥ 2 as a cut-point

)#2 B( #?(f6#1( 43$ B$(#1,8(00.(00 #00(00)(.1* !1 Y!88#803 %#1(;3$!F( # .6)B($ 34 =#1!(.10 Y!1, 02)=13)0 31,($1,#. B$(#1,8(00.(00 #0 ,#/!.; d4(Y 02)=13)0:e K3$ 1,!0$(#03.* 1,( 60( 34 # %3)=$(,(.0!/( 02)=13) #00(00)(.1!0 $(%3))(.?(?: <3Y(/($* B(%#60( 60( 34 1,( )"C+is still widespread, an mMRC of ≥ 2 is still included as a

%61W=3!.1 43$ 0(=#$#1!.; d8(00 B$(#1,8(00.(00e 4$3) d)3$(B$(#1,8(00.(00:e <3Y(/($* 60($0 #$( %#61!3.(? 1,#1#00(00)(.1 34 31,($ 02)=13)0 !0 $(f6!$(?iic*iii:

'UCJGBHDJCM %IIHIIBHED

(LAPH 8S= shows the classication of airow limitation

severity in COPD. Specic spirometric cut-points are

60(? 43$ =6$=30(0 34 0!)=8!%!12: I=!$3)(1$2 0,368? B(=($43$)(? #41($ 1,( #?)!.!01$#1!3. 34 #. #?(f6#1( ?30( 34# 0,3$1W#%1!.; !.,#8(? B$3.%,3?!8#13$ !. 3$?($ 13 )!.!)!F(/#$!#B!8!12:

<3Y(/($* 1,($( !0 3.82 # Y(#R %3$$(8#1!3. B(1Y((.KLN

_* 02)=13)0 #.? !)=#!$)(.1 34 # =#1!(.1E0 ,(#81,W

$(8#1(? f6#8!12 34 8!4(: H,!0 !0 !88601$#1(? !. ,CF@JH 8S8 !. Y,!%, ,(#81,W$(8#1(? f6#8!12 34 8!4( !0 =8311(? #;#!.01=301WB$3.%,3?!8#13$ KLN

__]m*_]n Y!1, 1,( 9Z5' 0=!$3)(1$!%

classication superimposed. The gure illustrates that,

Y!1,!. #.2 ;!/(. %#1(;3$2* =#1!(.10 )#2 ,#/( #.21,!.;B(1Y((. $(8#1!/(82 Y(88 =$(0($/(? 13 /($2 =33$ ,(#81,01#160: K3$ 1,!0 $(#03.* 43$)#8 02)=13)#1!% #00(00)(.1 !0#803 $(f6!$(?:

%IIHIIBHED GK *WLMHJALDCGE )CI_

An exacerbation of COPD is dened as an acute event%,#$#%1($!F(? B2 # Y3$0(.!.; 34 1,( =#1!(.1E0 $(0=!$#13$202)=13)0 1,#1 !0 B(23.? .3$)#8 ?#2W13W?#2 /#$!#1!3.0 #.?8(#?0 13 # %,#.;( !. )(?!%#1!3._]oW_b^: H,( $#1( #1 Y,!%,(M#%($B#1!3.0 3%%6$ /#$!(0 ;$(#182 B(1Y((. =#1!(.10_b_*i_]:H,( B(01 =$(?!%13$ 34 ,#/!.; 4$(f6(.1 (M#%($B#1!3.0 `]3$ )3$( (M#%($B#1!3.0 =($ 2(#$a !0 # ,!013$2 34 =$(/!3601$(#1(? (/(.10_b]. In addition, worsening airow limitation is

#003%!#1(? Y!1, #. !.%$(#0!.; =$(/#8(.%( 34 (M#%($B#1!3.0#.? $!0R 34 ?(#1,: <30=!1#8!F#1!3. 43$ # +ZJ' (M#%($B#1!3.!0 #003%!#1(? Y!1, # =33$ =$3;.30!0 Y!1, !.%$(#0(? $!0R 34?(#1,iim:

7 8#$;( B3?2 34 ?#1# ,#0 B((. #%%6)68#1(? !. =#1!(.10_b_*_i]

classied using GOLD spirometric grading systems. These

0,3Y #. !.%$(#0( !. $!0R 34 (M#%($B#1!3.0* ,30=!1#8!F#1!3.and death with worsening of airow limitation. The data

!. (LAPH 8S; #$( ?($!/(? 4$3) =$30=(%1!/(82 %388(%1(? ?#1#4$3) 8#$;( )(?!6)W1($) %8!.!%#8 1$!#80_b]W_bc: H,(2 #$( .31=$(%!0( (01!)#1(0 1,#1 #==82 13 (#%, =#1!(.1* B61 1,(2!88601$#1( %8(#$82 1,( !.%$(#0(? $!0R 34 (M#%($B#1!3.0 #.??(#1, B(1Y((. 0=!$3)(1$!% 8(/(80: C36;,82* #81,36;, 6= 13

Table 2.5. Classication of Severity of Airow

"CBCDLDCGE CE 5#3.

7$LIHO GE 3GIDb$JGEMNGOCPLDGJ ,*4:<

/E ULDCHEDI RCDN ,*4: `,45 c 9SZ9Y

9Z5' _j "!8? KLN_ ≥ oû =$(?!%1(?

GOLD 2: Moderate 50% ≤ FEV_ x oû =$(?!%1(?

GOLD 3: Severe 30% ≤ FEV_ x iû =$(?!%1(?

9Z5' cj N($2 I(/($( KLN_x bû =$(?!%1(?

,CF@JH 8S8S )HPLDCGEINCU $HDRHHE

-HLPDNbJHPLDHO a@LPCDQ GK "CKH1 3GIDbAJGEMNGOCPLDGJ

,*4: and GOLD Spirometric Classication

7%OLUDHO KJGB dGEHI:8Z<

8/16/2019 GOLD Report 2016


BI<=PL1I1 <PB <11K113KPG _i

20% of GOLD 2 (Moderate aiow limitation) patients may

(M=($!(.%( 4$(f6(.1 (M#%($B#1!3.0 $(f6!$!.; 1$(#1)(.1 Y!1,#.1!B!31!%0 #.?h3$ 0201()!% %3$1!%301($3!?0_b]* 1,( $!0R 34exacerbations signicantly increases in GOLD 3 (Severe)

#.? 9Z5' c `N($2 I(/($(a: I!.%( (M#%($B#1!3.0 !.%$(#0(1,( ?(%8!.( !. 86.; 46.%1!3.* ?(1($!3$#1!3. !. ,(#81, 01#160

#.? $!0R 34 ?(#1,* 1,( #00(00)(.1 34 (M#%($B#1!3. $!0R%#. #803 B( 0((. #0 #. #00(00)(.1 34 1,( $!0R 34 =33$361%3)(0 !. ;(.($#8:

(LAPH 8S;Y )/'] /0 5#3.Y 3PLMHAGbPCBA OLDL KJGB

(#)5-:TV>1 6UPCKD:TTe LEO *MPCUIH:T8 ≠

!#".

IUCJGBHDJCM

level

*WLMHJALDCGEI

(per year)*†≠ -GIUCDLPC^LDCGEI

(per year)* ≠

TbQHLJ

2GJDLPCDQ>e

./0" I? T#&5 ] ] ]

./0" E?

T'5*)32* J<N ̂ J<S J<II ̂ J<E II\!_

./0" M?@*B*)*

I<I ̂ I<M J<EF ̂ J<M IF\!

./0" H?

V*)A $*B*)* I<E ̂ E<J J<H ̂ J<FH EH\!

!>';3)5 3 C*B'&(2#'6 #6 1/K" ̀ *3&27 P>/C1`R $2(5AIMH

_ a65*)$2365#6= K'2*62#3& 0'6=D>*)- Q-43%2$ '6 W(6%2#'6 ;#27 >#'2)'4#(- PaK0QW>R $2(5AIMM

≠ Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) studyIME

%IIHIIBHED GK 5GBGJACOCDCHI

@(%#60( +ZJ' 341(. ?(/(83=0 !. 83.;W1!)( 0)3R($0 !.

)!??8( #;(* =#1!(.10 4$(f6(.182 ,#/( # /#$!(12 34 31,($ ?!0(#0(0 $(8#1(? 13 (!1,($ 0)3R!.; 3$ #;!.;_bi: +ZJ'itself also has signicant extrapulmonary (systemic) effects

!.%86?!.; Y(!;,1 8300* .61$!1!3.#8 #B.3$)#8!1!(0 #.? 0R(8(1#8)60%8( ?2046.%1!3.: H,( 8#11($ !0 %,#$#%1($!F(? B2 B31,0#$%3=(.!# `8300 34 )60%8( %(880a #.? #B.3$)#8 46.%1!3. 34 1,( $()#!.!.; %(880_bm: G10 %#60(0 #$( 8!R(82 )681!4#%13$!#8(inactivity, poor diet, inammation, hypoxia) and it can

%3.1$!B61( 13 (M($%!0( !.138($#.%( #.? =33$ ,(#81, 01#160 !.=#1!(.10 Y!1, +ZJ': G)=3$1#.182* 0R(8(1#8 )60%8( ?2046.%1!3.!0 # $()(?!#B8( 036$%( 34 (M($%!0( !.138($#.%(_bn:

+3)3$B!?!1!(0 1,#1 3%%6$ 4$(f6(.182 !. +ZJ' =#1!(.10

!.%86?( %#$?!3/#0%68#$ ?!0(#0(* 0R(8(1#8 )60%8( ?2046.%1!3.*)(1#B38!% 02.?$3)(* 301(3=3$30!0* ?(=$(00!3. #.? 86.;%#.%($: H,( (M!01(.%( 34 +ZJ' )#2 #%16#882 !.%$(#0(1,( $!0R 43$ 31,($ ?!0(#0(0g 1,!0 !0 =#$1!%68#$82 01$!R!.; 43$+ZJ' #.? 86.; %#.%($ _boW_c_: D,(1,($ 1,!0 #003%!#1!3. !0?6( 13 %3))3. $!0R 4#%13$0 `(:;:* 0)3R!.;a* !./38/()(.1 34060%(=1!B!8!12 ;(.(0* 3$ !)=#!$(? %8(#$#.%( 34 %#$%!.3;(.0!0 .31 %8(#$: +3)3$B!?!1!(0 %#. 3%%6$ !. =#1!(.10 Y!1, )!8?*moderate or severe airow limitation_b_, inuence mortality

#.? ,30=!1#8!F#1!3.0 !.?(=(.?(.182_c], and deserve specic

1$(#1)(.1: H,($(43$(* %3)3$B!?!1!(0 0,368? B( 833R(? 43$$361!.(82* #.? 1$(#1(? #==$3=$!#1(82* !. #.2 =#1!(.1 Y!1,+ZJ': H,( ;6!?(8!.(0 43$ 1,( ?!#;.30!0* #00(00)(.1 340(/($!12* #.? )#.#;()(.1 34 !.?!/!?6#8 %3)3$B!?!1!(0 !.

=#1!(.10 Y!1, +ZJ' #$( 1,( 0#)( #0 43$ #88 31,($ =#1!(.10: 7)3$( ?(1#!8(? ?(0%$!=1!3. 34 1,( )#.#;()(.1 34 +ZJ' #.?%3)3$B!?!1!(0 !0 ;!/(. !. +,#=1($ m:

5GBACEHO 5#3. %IIHIIBHED

7. 6.?($01#.?!.; 34 1,( !)=#%1 34 +ZJ' 3. #. !.?!/!?6#8=#1!(.1 %3)B!.(0 1,( 02)=13)#1!% #00(00)(.1 Y!1,the patient’s spirometric classication and/or risk of

(M#%($B#1!3.0: H,!0 #==$3#%, 13 %3)B!.(? #00(00)(.1 !0!88601$#1(? !. ,CF@JH 8ST:

70 ?(1#!8(? #B3/(* 1,( +7H !0 $(%3))(.?(? #0 #%3)=$(,(.0!/( )(#06$( 34 02)=13)0* Y!1, # +7H 0%3$(≥ 10 indicating a high level of symptoms. Comprehensive#00(00)(.1 34 1,( 02)=13)#1!% !)=#%1 34 1,( ?!0(#0( !0

=$(4($$(?* B61 !. !10 #B0(.%( )"C+ 0%3$(0 =$3/!?( #.#00(00)(.1 34 1,( !)=#%1 34 ?20=.(#: G1 !0 6..(%(00#$2#.? =300!B82 %3.460!.; 13 60( )3$( 1,#. 3.( 0%#8(:

H,($( #$( 1,$(( )(1,3?0 34 #00(00!.; (M#%($B#1!3.$!0R: Z.( !0 # =3=68#1!3.WB#0(? )(1,3? 60!.; 1,( 9Z5'spirometric classication ((LAPH 8S=a* Y!1, 9Z5' b 3$9Z5' c %#1(;3$!(0 !.?!%#1!.; ,!;, $!0R: H,( 0(%3.? B#0(?3. 1,( !.?!/!?6#8 =#1!(.1E0 ,!013$2 34 (M#%($B#1!3.0_b]*

,CF@JH 8STS %IIHIIBHED 6ICEF 'QBUDGBI1

Breathlessness, Spirometric Classication

LEO )CI_ GK *WLMHJALDCGEI

(C) (D)

(A) (B)

R i s k

( E x a c r b a t i o n

H i s t o r y )

R i s k

( G o l d

C l

a s s i fi c a t i o n

o f A i r fl o w L

i m i t a t i o n )

Symptoms

Breathlessness

CAT < 10 CAT ≥ 10

mMRC 0-1 mMRC ≥ 2

≥ 2

or

≥1 leading

to hospital

admission

1 (not leading

to hospital

admission)

0

8/16/2019 GOLD Report 2016


_m BI<=PL1I1 <PB <11K113KPG

Y!1, 1Y3 3$ )3$( (M#%($B#1!3.0 !. 1,( =$(%(?!.; 2(#$!.?!%#1!.; ,!;, $!0R: H,( 1,!$? !0 # ,!013$2 34 ,30=!1#8!F#1!3.?6( 13 #. (M#%($B#1!3. !. 1,( =$(%(?!.; 2(#$: `G4 1,($( !0# ?!0%$(=#.%2 B(1Y((. 1,(0( %$!1($!#* 1,( #00(00)(.1=3!.1!.; 13 1,( ,!;,(01 $!0R 0,368? B( 60(?:a H3 60( ,CF@JH8ST, rst assess symptoms with the CAT scale (or dyspneaY!1, 1,( )"C+a #.? ?(1($)!.( !4 1,( =#1!(.1 B(83.;0 13 1,(B3M(0 3. 1,( 8(41 0!?( r 5(00 I2)=13)0 `+7H x _â 3$ 5(00@$(#1,8(00.(00 `)"C+ ;$#?( ^W_ag 3$ B(83.;0 13 B3M(0on the right side - More Symptoms (CAT ≥ 10) or MoreBreathlessness (mMRC grade ≥ 2).

Q(M1 #00(00 1,( $!0R 34 (M#%($B#1!3.0 13 ?(1($)!.( !41,( =#1!(.1 B(83.;0 13 1,( 83Y($ =#$1 34 1,( B3M r 53YC!0R r 3$ 1,( 6==($ =#$1 34 1,( B3M r <!;, C!0R: H,!0 %#.B( ?3.( B2 3.( 34 1,$(( )(1,3?0j `_a 60( 0=!$3)(1$2 13determine the GOLD grade of airow limitation (GOLD 1#.? 9Z5' ] %#1(;3$!(0 !.?!%#1( 53Y C!0R* Y,!8( 9Z5' b#.? 9Z5' c !.?!%#1( <!;, C!0Rag `]a #00(00 1,( .6)B($34 (M#%($B#1!3.0 1,( =#1!(.1 ,#0 ,#? Y!1,!. 1,( =$(/!360

_] )3.1,0 `^ 3$ _ !.?!%#1(0 53Y C!0R* Y,!8( ] 3$ )3$((M#%($B#1!3.0 !.?!%#1(0 <!;, C!0Rag `ba ?(1($)!.( Y,(1,($1,( =#1!(.1 ,#0 ,#? 3.( 3$ )3$( ,30=!1#8!F#1!3. !. 1,(=$(/!360 2(#$ 43$ # +ZJ' (M#%($B#1!3.: G. 03)( =#1!(.10*1,(0( 1,$(( Y#20 34 #00(00!.; $!0R 34 (M#%($B#1!3.0 Y!88 .318(#? 13 1,( 0#)( 8(/(8 34 $!0Rg !. 1,!0 %#0(* 1,( $!0R 0,368?B( ?(1($)!.(? B2 1,( )(1,3? !.?!%#1!.; <!;, C!0R:

*WLBUPHj G)#;!.( # =#1!(.1 Y!1, # +7H 0%3$( 34 _o* KLN_

34 iiu 34 =$(?!%1(?* #.? # ,!013$2 34 b (M#%($B#1!3.0 Y!1,!.1,( 8#01 _] )3.1,0: I2)=13) #00(00)(.1 60!.; +7H0,3Y0 1,#1 1,( =#1!(.1 !0 "3$( I2)=13)#1!% `+7H ≥ _â#.? !0 1,($(43$( (!1,($ 9$36= @ 3$ 9$36= ': I=!$3)(1$2

!.?!%#1(0 53Y C!0R #0 1,( =#1!(.1 !0 9Z5' ] `"3?($#1(airow limitation) but as the patient had 3 exacerbations

Y!1,!. 1,( 8#01 _] )3.1,0 1,!0 !.?!%#1(0 <!;, C!0R #.?361Y(!;,0 1,( 83Y($ $!0R #00(00)(.1 B#0(? 3. 0=!$3)(1$2:H,( =#1!(.1 1,($(43$( B(83.;0 !. 9$36= ':

H,( ;$36=0 %#. B( 06))#$!F(? #0 43883Y0j

• 3LDCHED !JG@U % f "GR )CI_1 "HII 'QBUDGBITypically GOLD 1 or GOLD 2 (Mild or Moderate airow8!)!1#1!3.ag #.?h3$ ^W_ (M#%($B#1!3. =($ 2(#$ -%8 .3,30=!1#8!F#1!3. 43$ (M#%($B#1!3.g -%8 +7H 0%3$( x _^ 0.)"C+ ;$#?( ^W_

• 3LDCHED !JG@U $ f "GR )CI_1 2GJH 'QBUDGBITypically GOLD 1 or GOLD 2 (Mild or Moderate airow8!)!1#1!3.ag #.?h3$ ^W_ (M#%($B#1!3. =($ 2(#$ -%8 .3,30=!1#8!F#1!3. 43$ (M#%($B#1!3.g -%8 CAT score ≥ 10 0.mMRC grade ≥ 2

• 3LDCHED !JG@U 5 f -CFN )CI_1 "HII 'QBUDGBIH2=!%#882 9Z5' b 3$ 9Z5' c Ì(/($( 3$ N($2 I(/($(airow limitation); and/or ≥ 2 exacerbations per year 0. ≥ 1 with hospitalization 43$ (M#%($B#1!3.g -%8 +7H

0%3$( x _^ 0. )"C+ ;$#?( ^W_

• 3LDCHED !JG@U . f -CFN )CI_1 2GJH 'QBUDGBIH2=!%#882 9Z5' b 3$ 9Z5' c Ì(/($( 3$ N($2 I(/($(airow limitation); and/or ≥ 2 exacerbations per year0. ≥ 1 with hospitalization 43$ (M#%($B#1!3.g -%8 +7Hscore ≥ 10 0. mMRC grade ≥ 2

Evidence to support this classication system includes:

• J#1!(.10 Y!1, # ,!;, $!0R 34 (M#%($B#1!3.0 1(.? 13 B(!. 9Z5' %#1(;3$!(0 b #.? c Ì(/($( 3$ N($2 I(/($(airow limitation, ,CF@JH 8ST) and can be identied

f6!1( $(8!#B82 4$3) 1,( 1,(!$ 3Y. =#01 ,!013$2_b]:

• <!;,($ (M#%($B#1!3. $#1(0 #$( #003%!#1(? Y!1, 4#01($8300 34 KLN

__cb #.? ;$(#1($ Y3$0(.!.; 34 ,(#81,

01#160_cc:

• <30=!1#8!F#1!3. 43$ # +ZJ' (M#%($B#1!3. !0 #003%!#1(?Y!1, # =33$ =$3;.30!0iim:

• CAT scores ≥ 10 are associated with signicantly!)=#!$(? ,(#81, 01#160_ci:

L/(. !. 1,( #B0(.%( 34 4$(f6(.1 (M#%($B#1!3.0* =#1!(.10 !.9Z5' %#1(;3$!(0 b #.? c )#2 B( #1 ;$(#1($ $!0R 34 ,30=!1#8#?)!00!3. #.? ?(#1, `,CF@JH 8STa: H,(0( !)=3$1#.1!.%$(#0(? $!0R0 43$) 1,( $#1!3.#8( 43$ !.%86?!.; 06%,=#1!(.10 !. 1,( d<!;, C!0Re ;$36=0:

H,!0 #==$3#%,* %3)B!.(? Y!1, #. #00(00)(.1 34 =31(.1!#8comorbidities, reects the complexity of COPD better than

the unidimensional analysis of airow limitation previously

60(? 43$ 01#;!.; 1,( ?!0(#0( #.? 43$)0 1,( B#0!0 34 1,(;6!?( 13 !.?!/!?6#8!F(? )#.#;()(.1 =$3/!?(? !. +,#=1($ c:

Additional Investigations

H,( 43883Y!.; #??!1!3.#8 !./(01!;#1!3.0 )#2 B( %3.0!?($(?#0 =#$1 34 1,( ?!#;.30!0 #.? #00(00)(.1 34 +ZJ'j

Imaging. 7 %,(01 tW$#2 !0 .31 60(468 13 (01#B8!0, #?!#;.30!0 !. +ZJ'* B61 !1 !0 /#86#B8( !. (M%86?!.;#81($.#1!/( ?!#;.30(0 #.? (01#B8!0,!.; 1,( =$(0(.%( 34signicant comorbidities such as concomitant respiratory(pulmonary brosis, bronchiectasis, pleural diseases),

0R(8(1#8 `(:;:* R2=,30%38!30!0a* #.? %#$?!#% ?!0(#0(0`(:;:* %#$?!3)(;#82a: C#?!383;!%#8 %,#.;(0 #003%!#1(?with COPD include signs of lung hyperination (atteneddiaphragm on the lateral chest lm, and an increase in1,( /386)( 34 1,( $(1$301($.#8 #!$ 0=#%(a* ,2=($86%(.%234 1,( 86.;0* #.? $#=!? 1#=($!.; 34 1,( /#0%68#$ )#$R!.;0:+3)=61(? 13)3;$#=,2 `+Ha 34 1,( %,(01 !0 .31 $361!.(82$(%3))(.?(?: <3Y(/($* Y,(. 1,($( !0 ?36B1 #B3611,( ?!#;.30!0 34 +ZJ'* +H 0%#..!.; )!;,1 ,(8= !. 1,(?!44($(.1!#8 ?!#;.30!0 Y,($( %3.%3)!1#.1 ?!0(#0(0 #$(

8/16/2019 GOLD Report 2016


BI<=PL1I1 <PB <11K113KPG _n

=$(0(.1: G. #??!1!3.* !4 # 06$;!%#8 =$3%(?6$( 06%, #0 86.;/386)( $(?6%1!3. !0 %3.1()=8#1(?* # %,(01 +H 0%#. !0.(%(00#$2 0!.%( 1,( ?!01$!B61!3. 34 ()=,20()# !0 3.( 341,( )301 !)=3$1#.1 ?(1($)!.#.10 34 06$;!%#8 06!1#B!8!12_cm:

Lung Volumes and Diffusing Capacity. +ZJ' =#1!(.10(M,!B!1 ;#0 1$#==!.; `# $!0( !. $(0!?6#8 /386)(a 4$3)early in the disease, and as airow limitation worsens

static hyperination (an increase in total lung capacity)

3%%6$0: H,(0( %,#.;(0 %#. B( ?3%6)(.1(? B2 B3?2=8(1,20)3;$#=,2* 3$ 8(00 #%%6$#1(82 B2 ,(8!6) ?!861!3.86.; /386)( )(#06$()(.1: H,(0( )(#06$()(.10 ,(8=%,#$#%1($!F( 1,( 0(/($!12 34 +ZJ' B61 #$( .31 (00(.1!#8 13=#1!(.1 )#.#;()(.1: "(#06$()(.1 34 ?!4460!.; %#=#%!12`'5

+Za =$3/!?(0 !.43$)#1!3. 3. 1,( 46.%1!3.#8 !)=#%1 34

()=,20()# !. +ZJ' #.? !0 341(. ,(8=468 !. =#1!(.10 Y!1,B$(#1,8(00.(00 1,#1 )#2 0(() 361 34 =$3=3$1!3. Y!1, 1,(degree of airow limitation.

Oximetry and Arterial Blood Gas Measurement. J680(3M!)(1$2 %#. B( 60(? 13 (/#86#1( # =#1!(.1E0 3M2;(.0#16$#1!3. #.? .((? 43$ 06==8()(.1#8 3M2;(. 1,($#=2:J680( 3M!)(1$2 0,368? B( 60(? 13 #00(00 #88 01#B8(=#1!(.10 Y!1, KLN

_ x biu =$(?!%1(? 3$ Y!1, %8!.!%#8 0!;.0

06;;(01!/( 34 $(0=!$#13$2 4#!86$( 3$ $!;,1 ,(#$1 4#!86$(: G4=($!=,($#8 0#16$#1!3. !0 x l]u #$1($!#8 B833? ;#0(0 0,368?B( #00(00(?_cn:

Alpha-1 Antitrypsin Deciency Screening. H,( D3$8?<(#81, Z$;#.!F#1!3. $(%3))(.?0 1,#1 +ZJ' =#1!(.104$3) #$(#0 Y!1, # =#$1!%68#$82 ,!;, =$(/#8(.%( 34 #8=,#W_antitrypsin deciency should be screened for this genetic

?!03$?($ _co: <3Y(/($* 1,( 12=!%#8 =#1!(.1 1(.?0 13 =$(0(.1#1 # 236.;($ #;( `x ci 2(#$0a Y!1, 83Y($ 83B( ()=,20()#:Family members can be identied and family screening is

60(468 43$ #==$3=$!#1( %36.0(8!.;: 7 0($6) %3.%(.1$#1!3.34 #8=,#W_ #.1!1$2=0!. B(83Y _iW]^u 34 1,( .3$)#8 /#86(!0 ,!;,82 06;;(01!/( 34 ,3)3F2;360 #8=,#W_ #.1!1$2=0!.deciency.

Exercise Testing. ZB\(%1!/(82 )(#06$(? (M($%!0(!)=#!$)(.1* #00(00(? B2 # $(?6%1!3. !. 0(84W=#%(?Y#8R!.; ?!01#.%(_cl 3$ ?6$!.; !.%$()(.1#8 (M($%!0( 1(01!.;!. # 8#B3$#13$2_i^* !0 # =3Y($468 !.?!%#13$ 34 ,(#81, 01#160!)=#!$)(.1 #.? =$(?!%13$ 34 =$3;.30!0_i_ g (M($%!0( %#=#%!12

)#2 4#88 !. 1,( 2(#$ B(43$( ?(#1,iin: D#8R!.; 1(010 %#. B(60(468 43$ #00(00!.; ?!0#B!8!12 #.? #$( 60(? 13 #00(00 1,((44(%1!/(.(00 34 =68)3.#$2 $(,#B!8!1#1!3.: @31, 1,( =#%(?0,6118( Y#8R 1(010_i]*_ib #.? 1,( 6.=#%(? mW)!.61( Y#8R 1(01%#. B( 60(?_ic: 70 1,( %36$0( 8(.;1, ,#0 # 06B01#.1!#8!)=#%1 3. 1,( ?!01#.%( Y#8R(?* (M!01!.; $(4($(.%((f6#1!3.0 (01#B8!0,(? 43$ # b^ ) %36$0( %#..31 B( #==8!(?13 =$(?!%1 1,( ?!01#.%( #%,!(/(? 3. 0,3$1($ %36$0(0ioi:5#B3$#13$2 1(01!.; 60!.; %2%8( 3$ 1$(#?)!88 ($;3)(1$2 %#.

!?(.1!42 %3W(M!01!.; 3$ #81($.#1!/( %3.?!1!3.0* (:;:* %#$?!#%?!#;.30(0: "3.!13$!.; 34 =,20!%#8 #%1!/!12 )#2 B( )3$($(8(/#.1 $(;#$?!.; =$3;.30!0 1,#. (/#86#1!.; (M($%!0(%#=#%!12_ii: H,!0 %#. B( ?3.( 60!.; #%%(8($3)(1($0 3$)681!0(.03$ !.01$6)(.10:

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H'5&41'3%5 N'5&41*0%5Q 100, 200 (MDI DPI) D mg (Pill), 0.02(Syrup) 0.1, 0. A7E

$*0&41'5-,* 00, 00 (DPI) 2., mg (Pill) A7E

ongacting L%03%1*0%5 .-12 (MDI DPI) M"M!U !9

K0;%03%1*0%5 M"MMVD !9

P,)'('1*0%5 7-00 (DPI) 9A

W5%)'1*0%5 D NHOPQ 9A

H'53*1*0%5 2-0 (MDI DPI) !9

$45%&41*0%5 9 36 N10',.)*03'5Q 9A

#>7:516A:>83?:5;

hortacting

P+0'10%+-43 &0%3-)* 20, 0 (MDI) M"9D7M"D E7G

W<-10%+-43 &0%3-)* !MM NOJPQ !"D V7T

ongacting

K(5-)-,-43 &0%3-)* 22 (DPI) !9

X5?(%+?00%,-43 &0%3-)* (DPI) 9A

$-%10%+-43 1 (DPI), (SMI) 9A

Y3*(5-)-,-43 62. (DPI) 9A

!64@:>27:6> ;1637W257:>? @872DW2?6>:;7 9AK; 2>7:516A:>83?:5 :> 6>8 :>12A83

L*,%1*0%5ZP+0'10%+-43 9MMZGM NOJPQ !"9DZM"D E7G

H'5&41'3%5ZP+0'10%+-43 !MMZ9M NHOPQ E7G

!64@:>27:6> A6>?W257:>? @872DW2?6>:;7 9AK; 2>7:516A:>83?:5 :> 6>8 :>12A83

L%03%1*0%5Z'(5-)-,-43 12/0 (DPI) !9

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W5*)%1'0%5Z1-%10%+-43 DZD NHOPQ 9A

[-5',1*0%5Z43*(5-)-,-43 2/62. (DPI) 9A

H871]Ac2>71:>8;

K3-,%+/?55-,* 200-600 mg (Pill) 9AM Variable, up to 2

$/*%+/?55-,* NH\Q 100-600 mg (Pill) Variable, up to 2

->12A8F 5637:56;7836:F;

B*(5%3*1/'.%,* 0-00 (MDI DPI) M"97M"A

B4)*.%,-)* 100, 200, 00 (DPI) 0.20. 0.2, 0.

L541-('.%,* 0-00 (MDI DPI)

!64@:>27:6> A6>?W257:>? @872DW2?6>:;7; 9AK; 5637:56;7836:F; :> 6>8 :>12A83

L%03%1*0%5Z&*(5%3*1'.%,* EZ!MM NOJPQ

L%03%1*0%5Z&4)*.%,-)* A"DZ!EM NOJPQ

/20 (DPI)

L%03%1*0%5Z3%3*1'.%,* 10/200, 10/00 (MDI)

H'53*1*0%5ZL541-('.%,* 0/100, 20, 00 (DPI)

[-5',1*0%5ZL541-('.%,* ;40%'1* 2/100 (DPI)

/];784:5 5637:56;7836:F;

Prednisone -60 mg (Pill)

O*1/?57+0*),-.%5%,* , , 16 mg (Pill)

$16;916F:8;7832;8WZ :>1:@:763;

Roumilast 00 mcg (Pill) 9A

MDImetered dose inhaler; DPIdry powder inhaler; SMIsoft mist inhaler ot all formulations are available in all countries; in some countries, other formulations may be available.UL%03%1*0%5 ,*&45-@*) .%541-%, -. &'.*) %, 1/* 4,-1 )%.* 8-'5 (%,1'-,-,6 9M 3(6 -, ' 8%543* %; 9"M 35

8/16/2019 GOLD Report 2016


!"#$%&#'!() +&!(+,- !Q

W5.%3-.9):'(.5 /*9)3'().%+ '5* 2)4*% .% *)(-*5 '% '+<%**9*9 ;'+)+ .5 ' 5*2>:'5 ;'+)+ (. &5*4*%( .5 5*9>3*+6/&(./+MZK<MZZ O&E:F8>58 #) (%2@A8 (BZ).?316

@ A6>02.;1;< E-* &5)%3)&': '3().% .B ;*('

!<'2.%)+(+

)+ (. 5*:'D ')5,'6 +/..(- />+3:* ;6 +()/>:'()%2 ;*('!<

adrenergic receptors, which increases cyclic AMP and&5.9>3*+ B>%3().%': '%('2.%)+/ (. ;5.%3-.3.%+(5)3().%7E-* ;5.%3-.9):'(.5 *BB*3(+ .B +-.5(<'3()%2 ;*('

!<'2.%)+(+

>+>'::6 ,*'5 .BB ,)(-)% T (. P -.>5+MNM1MN!7 U*2>:'5 '%9 '+<needed use of short-acting beta-agonists improve FEV

M

'%9 +6/&(./+MNQ O&E:F8>58 R). The use of high doses.B +-.5(<'3()%2 ;*('

!<'2.%)+(+ .% '% '+<%**9*9 ;'+)+ )%

&'()*%(+ ':5*'96 (5*'(*9 ,)(- :.%2<'3()%2 ;5.%3-.9):'(.5+ )+%.( +>&&.5(*9 ;6 *4)9*%3*1 /'6 ;* :)/)(*9 ;6 +)9* *BB*3(+1and cannot be recommended. For single-dose, as-needed

>+* )% ?@8A1 (-*5* '&&*'5+ (. ;* %. '94'%('2* )% >+)%2:*4':;>(*5.: .4*5 3.%4*%().%': ;5.%3-.9):'(.5+MNT7

\.%2<'3()%2 )%-':*9 ;*('!<'2.%)+(+ +-., 9>5'().% .B '3().%

of 12 or more hours. Formoterol and salmeterol signicantlyimprove FEV

M '%9 :>%2 4.:>/*+1 96+&%*'1 -*':(-<5*:'(*9

C>':)(6 .B :)B* '%9 *D'3*5;'().% 5'(*MNK<!"" _&E:F8>58 #),;>( -'4* %. *BB*3( .% /.5(':)(6 '%9 5'(* .B 9*3:)%* .B :>%2B>%3().%7 = +6+(*/'()3 5*4)*, .B (5)':+ .B +':/*(*5.: '%9formoterol showed a signicant reduction in the numbers.B &'()*%(+ 5*C>)5)%2 (5*'(/*%( B.5 *D'3*5;'().%+ '%9 (-*number requiring hospitalizationKZP7 J':/*(*5.: 5*9>3*+the rate of hospitalizationMNK O&E:F8>58 R). Indacaterol)+ ' .%3* 9'):6 ;*('

!

<'2.%)+( ,)(- ' 9>5'().% .B '3().% .B!T -.>5+!"M1!"!. The bronchodilator effect is signicantly25*'(*5 (-'% (-'( .B B.5/.(*5.: '%9 +':/*(*5.:1 '%9 +)/):'5(. ().(5.&)>/ O&E:F8>58 #). Indacaterol has signicant*BB*3(+ .% ;5*'(-:*++%*++1 -*':(- +('(>+ '%9 *D'3*5;'().%5'(* O&E:F8>58 R). Its safety prole is similar to placebo;in clinical trials a signicant number of patients (24%vs 7%) experienced cough following the inhalation of)%9'3'(*5.:KMQ<KMP7

%9B38;3 3CC3/1;7 J()/>:'().% .B ;*('!<'95*%*52)3

5*3*&(.5+ 3'% &5.9>3* 5*+()%2 +)%>+ ('3-63'59)' '%9 -'+(-* &.(*%()': (. &5*3)&)('(* 3'59)'3 5-6(-/ 9)+(>5;'%3*+)% +>+3*&();:* &'()*%(+1 ':(-.>2- (-*+* +**/ (. -'4*5*/'50';:6 B*, 3:)%)3': )/&:)3'().%+7 FD'22*5'(*9 +./'()3(5*/.5 )+ (5.>;:*+./* )% +./* .:9*5 &'()*%(+ (5*'(*9,)(- -)2-*5 9.+*+ .B ;*('

!<'2.%)+(+1 ,-'(*4*5 (-* 5.>(*

.B '9/)%)+(5'().%1 '%9 (-)+ :)/)(+ (-* 9.+* (-'( 3'% ;*(.:*5'(*97 =:(-.>2- -6&.0':*/)' 3'% .33>51 *+&*3)'::6when treatment is combined with thiazide diuretics!"Q1'%9 .D62*% 3.%+>/&().% 3'% ;* )%35*'+*9 >%9*5 5*+()%23.%9)().%+!"T1 (-*+* /*(';.:)3 *BB*3(+ +-., ('3-6&-6:'D)+unlike the bronchodilator actions. Mild falls in PaO

! 3'%

.33>5 'B(*5 '9/)%)+(5'().% .B ;.(- +-.5(<'%9 :.%2<'3()%2;*('

!<'2.%)+(+!"K1!"P but the clinical signicance of these

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%21./=05.238>./;< E-* /.+( )/&.5('%( *BB*3( )% ?@8A&'()*%(+ .B '%()3-.:)%*52)3 /*9)3'().%+1 +>3- '+ )&5'(5.&)>/.D)(5.&)>/ '%9 ().(5.&)>/ ;5./)9*1 '&&*'5+ (. ;* ;:.30'2*.B '3*(6:3-.:)%*G+ *BB*3( .% />+3'5)%)3 5*3*&(.5+7 ?>55*%(short-acting drugs block M2 and M3 receptors and modify(5'%+/)++).% '( (-* &5*<2'%2:).%)3 R>%3().%1 ':(-.>2- (-*+**BB*3(+ '&&*'5 :*++ )/&.5('%( )% ?@8A!"V7 E-* :.%2<'3()%2'%()3-.:)%*52)3 ().(5.&)>/ -'+ ' &-'5/'3.0)%*()3 +*:*3()4)(6for the M3 and M1 receptors!"Z7 E-* ;5.%3-.9):'()%2*BB*3( .B +-.5(<'3()%2 )%-':*9 '%()3-.:)%*52)3+ :'+(+ :.%2*5(-'% (-'( .B +-.5(<'3()%2 ;*('

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7

=/.%2 :.%2<'3()%2 '%()3-.:)%*52)3+1 '33:)9)%)>/ -'+ '9>5'().% .B '( :*'+( M! -.>5+KK! ,-*5*'+ ().(5.&)>/ '%92:63.&655.%)>/ -'4* ' 9>5'().% .B '3().% .B /.5* (-'%!T -.>5+!"N<!MM7 E).(5.&)>/ 5*9>3*+ *D'3*5;'().%+ '%9related hospitalizations, improves symptoms and health+('(>+!M!1 KZV O&E:F8>58 #), and improves the effectiveness.B &>:/.%'56 5*-';):)('().%!MQ O&E:F8>58 R). In a large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

%9B38;3 3CC3/1;< =%()3-.:)%*52)3 95>2+ '5* &..5:6 ';+.5;*9,-)3- :)/)(+ (-* (5.>;:*+./* +6+(*/)3 *BB*3(+ +**% ,)(-'(5.&)%*!MP7 FD(*%+)4* >+* .B (-)+ 3:'++ .B )%-':*9 '2*%(+

%2@A8 (BZB R36>516F:A2763; :> /72@A8 !,$J

• B0%,(/%)-5'1%0 3*)-('1-%,. '0* (*,10'5 1% .?3+1%3 3','6*3*,1 -,

COPD.•

P,/'5*) 1/*0'+? -. +0*;*00*)"• $/* (/%-(* &*12**, &*1'

9-agonist, anticholinergic, theophylline, or

(%3&-,'1-%, 1/*0'+? )*+*,). %, '8'-5'&-5-1? ',) -,)-8-)4'5 +'1-*,1

0*.+%,.* -, 1*03. %; .?3+1%3 0*5-*; ',) .-)* *;;*(1."

• B0%,(/%)-5'1%0. '0* +0*.(0-&*) %, ', '.7,**)*) %0 %, ' 0*645'0 &'.-.

1% +0*8*,1 %0 0*)4(* .?3+1%3."

• S%,67'(1-,6 -,/'5*) &0%,(/%)-5'1%0. '0* (%,8*,-*,1 ',) 3%0*

*;;*(1-8* '1 +0%)4(-,6 3'-,1'-,*) .?3+1%3 0*5-*; 1/', ./%017'(1-,6

&0%,(/%)-5'1%0."

• >%3&-,-,6 &0%,(/%)-5'1%0. %; )-;;*0*,1 +/'03'(%5%6-('5 (5'..*. 3'?

improve efcacy and decrease the risk of side effects compared to-,(0*'.-,6 1/* )%.* %; ' .-,65* &0%,(/%)-5'1%0"

8/16/2019 GOLD Report 2016


!T !"#$%&#'!() +&!(+,-

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a signicantly increased risk of mortality compared with&:'3*;. )% ' /*('<'%':6+)+KMN; however, the ndings of(-* E$@J8$U] (5)': +-.,*9 (-'( (-*5* ,'+ %. 9)BB*5*%3*)% /.5(':)(6 .5 5'(*+ .B *D'3*5;'().% ,-*% 3./&'5)%2().(5.&)>/ )% ' 956<&.,9*5 )%-':*5 (. (-* U*+&)/'(] )%-':*5 KKN7 ^+* .B +.:>().%+ ,)(- ' B'3* /'+0 -'+ ;**%5*&.5(*9 (. &5*3)&)('(* '3>(* 2:'>3./'1 &5.;';:6 ;6 ' 9)5*3(*BB*3( .B (-* +.:>().% .% (-* *6*7

D31=E5F621=.23;7 ?.%(5.4*5+6 5*/')%+ ';.>( (-**D'3( *BB*3(+ .B D'%(-)%* 9*5)4'()4*+7 E-*6 /'6 '3( '+%.%+*:*3()4* &-.+&-.9)*+(*5'+* )%-);)(.5+1 ;>( -'4* ':+.;**% 5*&.5(*9 (. -'4* ' 5'%2* .B %.%<;5.%3-.9):'(.5actions, the signicance of which is disputed!!"<!!T7 A'(' .%9>5'().% .B '3().% B.5 3.%4*%().%':1 .5 *4*% +:.,<5*:*'+*1D'%(-)%* &5*&'5'().%+ '5* :'30)%2 )% ?@8A7

E-*.&-6::)%*1 (-* /.+( 3.//.%:6 >+*9 /*(-6:D'%(-)%*1 )+metabolized by cytochrome P450 mixed function oxidases.Clearance of the drug declines with age. Many other&-6+).:.2)3': 4'5)';:*+ '%9 95>2+ /.9)B6 (-*.&-6::)%*

/*(';.:)+/7 ?-'%2*+ )% )%+&)5'(.56 />+3:* B>%3().% -'4*;**% 5*&.5(*9 )% &'()*%(+ (5*'(*9 ,)(- (-*.&-6::)%*!!"1 ;>(whether this reects changes in spirometry or a primary*BB*3( .% (-* />+3:* )+ %.( 3:*'57 =:: +(>9)*+ (-'( -'4*shown efcacy of theophylline in COPD were performed,)(- +:.,<5*:*'+* &5*&'5'().%+7

E-*.&-6::)%* )+ :*++ *BB*3()4* '%9 :*++ ,*:: (.:*5'(*9(-'% )%-':*9 :.%2<'3()%2 ;5.%3-.9):'(.5+!!K '%9 )+ %.(5*3.//*%9*9 )B (-.+* 95>2+ '5* '4'):';:* '%9 'BB.59';:*7[.,*4*51 (-*5* )+ *4)9*%3* B.5 ' /.9*+( ;5.%3-.9):'(.5*BB*3( 3./&'5*9 ,)(- &:'3*;. )% +(';:* ?@8A!!P O&E:F8>58#). There is also some evidence of symptomatic benet3./&'5*9 (. &:'3*;.!!V7 =99)().% .B (-*.&-6::)%* (.salmeterol produced a greater improvement in FEV

M '%9

;5*'(-:*++%*++ (-'% +':/*(*5.: ':.%*!!Z O&E:F8>58 R).\.,<9.+* (-*.&-6::)%* 5*9>3*+ *D'3*5;'().%+ ;>( 9.*+ %.()/&5.4* &.+(<;5.%3-.9):'(.5 :>%2 B>%3().%!!V O&E:F8>58 R).

%9B38;3 3CC3/1;7 E.D)3)(6 )+ 9.+*<5*:'(*91 ' &'5()3>:'5&5.;:*/ ,)(- (-* D'%(-)%* 9*5)4'()4*+ ;*3'>+* (-*)5therapeutic ratio is small and most of the benet.33>5+ .%:6 ,-*% %*'5<(.D)3 9.+*+ '5* 2)4*%!!M1!!Q1!!N7

Methylxanthines are nonspecic inhibitors of allphosphodiesterase enzyme subsets, which explains(-*)5 ,)9* 5'%2* .B (.D)3 *BB*3(+7 85.;:*/+ )%3:>9* (-*9*4*:.&/*%( .B '(5)': '%9 4*%(5)3>:'5 '55-6(-/)'+ O,-)3-can prove fatal) and grand mal convulsions (whichcan occur irrespective of prior epileptic history). Other+)9* *BB*3(+ )%3:>9* -*'9'3-*+1 )%+./%)'1 %'>+*'1 '%9-*'5(;>5%1 '%9 (-*+* /'6 .33>5 ,)(-)% (-* (-*5'&*>()35'%2* .B +*5>/ (-*.&-6::)%*7 E-*+* /*9)3'().%+ ':+. -'4*signicant interactions with commonly used medications+>3- '+ 9)2)(':)+1 3.>/'9)%1 *(37 ^%:)0* (-* .(-*5;5.%3-.9):'(.5 3:'++*+1 D'%(-)%* 9*5)4'()4*+ /'6 )%4.:4* 'risk of overdose (either intentional or accidental).

)07G.261.02 ?802/=09.56108 !=3864E< ?./;)%)%2;5.%3-.9):'(.5+ ,)(- 9)BB*5*%( /*3-'%)+/+ '%9 9>5'().%+.B '3().% /'6 )%35*'+* (-* 9*25** .B ;5.%3-.9):'().%B.5 *C>)4':*%( .5 :*++*5 +)9* *BB*3(+!Q". For example,' 3./;)%'().% .B ' +-.5(<'3()%2 ;*('

!<'2.%)+( '%9 '%

'%()3-.:)%*52)3 &5.9>3*+ 25*'(*5 '%9 /.5* +>+(')%*9

improvements in FEVM (-'% *)(-*5 95>2 ':.%* '%9 9.*+%.( &5.9>3* *4)9*%3* .B ('3-6&-6:'D)+ .4*5 N" 9'6+ .B(5*'(/*%(MNM1!QM1!Q!7 E-* 3./;)%'().% .B ' ;*('

!<'2.%)+(1

'% '%()3-.:)%*52)31 '%9Y.5 (-*.&-6::)%* /'6 &5.9>3*'99)().%': )/&5.4*/*%(+ )% :>%2 B>%3().%MNM1!!T1!!Z1!QM<!QK '%9 -*':(- +('(>+MNM1!QP7 J-.5(<(*5/ 3./;)%'().% (-*5'&6>+)%2 B.5/.(*5.: '%9 ().(5.&)>/ -'+ ;**% +-.,% (. -'4*a bigger impact on FEV

M (-'% (-* +)%2:* 3./&.%*%(+!QV1!QZ

O&E:F8>58 R). Combinations of short-acting beta!<'2.%)+(+

'%9 '%()3-.:)%*52)3+ '5* ':+. +>&*5).5 3./&'5*9 (. *)(-*5medication alone in improving FEV

M '%9 +6/&(./+!QM

O&E:F8>58 R). Combinations of a long-acting beta!<'2.%)+(

and a long-acting anticholinergic have shown a signicant

)%35*'+* )% :>%2 B>%3().% ,-*5*'+ (-* )/&'3( .% &'()*%(5*&.5(*9 .>(3./*+ )+ +():: :)/)(*9KP"1 KZN7 E-*5* )+ +():: (..:)((:* *4)9*%3* (. 9*(*5/)%* )B ' 3./;)%'().% .B :.%2<'3()%2 ;5.%3-.9):'(.5+ )+ /.5* *BB*3()4* (-'% ' :.%2<'3()%2'%()3-.:)%*52)3 ':.%* B.5 &5*4*%()%2 *D'3*5;'().%+KPM7

!637:56;7836:F;

(2=6539 )081./0;1380.9;< E-* 9.+*<5*+&.%+*5*:'().%+-)&+ '%9 :.%2<(*5/ +'B*(6 .B )%-':*9 3.5()3.+(*5.)9+)% ?@8A '5* %.( 0%.,%7 @%:6 /.9*5'(* (. -)2- 9.+*+have been used in long-term clinical trials. The efcacy'%9 +)9* *BB*3(+ .B )%-':*9 3.5()3.+(*5.)9+ )% '+(-/' '5*9*&*%9*%( .% (-* 9.+* '%9 (6&* .B 3.5()3.+(*5.)9!QN1 ;>(

,-*(-*5 (-)+ )+ ':+. (-* 3'+* )% ?@8A )+ >%3:*'57 E-**BB*3(+ .B 3.5()3.+(*5.)9+ .% &>:/.%'56 '%9 +6+(*/)3inammation in patients with COPD are controversial, and(-*)5 5.:* )% (-* /'%'2*/*%( .B +(';:* ?@8A )+ :)/)(*9 (.specic indications.

U*2>:'5 (5*'(/*%( ,)(- )%-':*9 3.5()3.+(*5.)9+ )/&5.4*++6/&(./+1 :>%2 B>%3().%1 '%9 C>':)(6 .B :)B*1 '%9 5*9>3*+(-* B5*C>*%36 .B *D'3*5;'().%+MTT )% ?@8A &'()*%(+ ,)(- '%FEV

M _ P"L &5*9)3(*9MNK1!T"<!TT O&E:F8>58 #). Withdrawal

8/16/2019 GOLD Report 2016


!"#$%&#'!() +&!(+,- !K

B5./ (5*'(/*%( ,)(- )%-':*9 3.5()3.+(*5.)9+ /'6 :*'9 (.*D'3*5;'().%+ )% +./* &'()*%(+!TK1 ':(-.>2- )% '%.(-*5+(>96 ,)(- +*4*5* '%9 4*56 +*4*5* ?@8A &'()*%(+1 )%-':*93.5()3.+(*5.)9+ 3.>:9 ;* 25'9>'::6 ,)(-95',% .4*5 ' (-5**</.%(- &*5).9 ,)(-.>( )%35*'+)%2 (-* /*9)>/ (*5/ 5)+0.B *D'3*5;'().%+1 ':(-.>2- :>%2 B>%3().% 9*(*5).5'(*9signicantlyKN"7 X)(-95',': .B )%-':*9 3.5()3.+(*5.)9+1

)% ?@8A &'()*%(+ '( :., 5)+0 .B *D'3*5;'().%1 3'% ;*+'B* &5.4)9*9 (-'( &'()*%(+ '5* :*B( .% /')%(*%'%3*(5*'(/*%( ,)(- :.%2<'3()%2 ;5.%3-.9):'(.5+PMZ7 U*2>:'5(5*'(/*%( ,)(- )%-':*9 3.5()3.+(*5.)9+ 9.*+ %.( /.9)B6 (-*long-term decline of FEV

M %.5 /.5(':)(6 )% &'()*%(+ ,)(-

?@8AM!P1MVK1MVP1MNK1!TP1!TV1K!" O&E:F8>58 #`7

%9B38;3 3CC3/1;< $%-':*9 3.5()3.+(*5.)9 >+* )+ '++.3)'(*9,)(- -)2-*5 &5*4':*%3* .B .5': 3'%9)9)'+)+1 -.'5+*4.)3*1 '%9 +0)% ;5>)+)%2M!P1MVK7 E5*'(/*%( ,)(- )%-':*93.5()3.+(*5.)9+ )+ '++.3)'(*9 ,)(- '% )%35*'+*9 5)+0 .B&%*>/.%)'MNK1!TP<!TZ1KNM7 X-):* :.%2<(*5/ (5*'(/*%( ,)(-(5)'/3)%.:.%* '3*(.%)9* )+ '++.3)'(*9 ,)(- '% )%35*'+*9

5)+0 .B 5*9>3*9 ;.%* 9*%+)(61 (-* *4)9*%3* ,)(- .(-*5)%-':*9 3.5()3.+(*5.)9+ )+ 3.%(5.4*5+)':7 @%* :.%2<(*5/+(>96 +-.,*9 %. *BB*3( .B ;>9*+.%)9* .% ;.%* 9*%+)(6'%9 B5'3(>5* 5'(*MVK1!TN1 '%9 (5*'(/*%( .4*5 ' (-5**<6*'5period with 500 mcg bid uticasone propionate alone or)% 3./;)%'().% ,)(- +':/*(*5.: ,'+ %.( '++.3)'(*9 ,)(-9*35*'+*9 ;.%* /)%*5': 9*%+)(6 )% ' &.&>:'().% .B ?@8A&'()*%(+ ,)(- -)2- &5*4':*%3* .B .+(*.&.5.+)+!K"7

)07G.261.02 (2=6539 )081./0;1380.9H?802/=09.56108!=3864E< =% )%-':*9 3.5()3.+(*5.)9 3./;)%*9 ,)(- ' :.%2<'3()%2 ;*('

!<'2.%)+( )+ /.5* *BB*3()4* (-'% (-* )%9)4)9>':

3./&.%*%(+ )% )/&5.4)%2 :>%2 B>%3().% '%9 -*':(- +('(>+

'%9 5*9>3)%2 *D'3*5;'().%+ )% &'()*%(+ ,)(- /.9*5'(*O&E:F8>58 R) to very severe COPDMNK1!T"1!TQ1!TT1!TP1!KM<!KQ1K!M1K!! O&E:F8>58 #). An inhaled corticosteroid/long-acting;*('

!<'2.%)+( 3./;)%'().% 2)4*% .%3* 9'):6 9.*+ %.(

show relevant differences regarding efcacy compared(. (,)3* 9'):6PMN7 = :'52* &5.+&*3()4* 3:)%)3': (5)': B'):*9 (.demonstrate a statistically signicant effect of combination(-*5'&6 .% /.5(':)(6MNK1 ;>( ' +>;+*C>*%( /*('<'%':6+)+B.>%9 (-'( 3./;)%'().% (-*5'&6 /'6 5*9>3* /.5(':)(6with a number needed to treat (NNT) of 3!KT O&E:F8>58R). Combination therapy is associated with an increased5)+0 .B &%*>/.%)'!KK, but no other signicant side effectO&E:F8>58 #). The addition of a long-acting beta

!<'2.%)+(Y

)%-':*9 3.5()3.+(*5.)9 3./;)%'().% (. ().(5.&)>/ )/&5.4*+:>%2 B>%3().% '%9 C>':)(6 .B :)B*!KP1!KV '%9 /'6 B>5(-*5 5*9>3**D'3*5;'().%+ O&E:F8>58 R) but more studies of triple(-*5'&6 '5* %**9*9!KZ7

+865 )081./0;1380.9;< @5': 3.5()3.+(*5.)9+ -'4* %>/*5.>++)9* *BB*3(+KN!7 =% )/&.5('%( +)9* *BB*3( .B :.%2<(*5/ (5*'(/*%( .B?@8A ,)(- +6+(*/)3 3.5()3.+(*5.)9+ )+ +(*5.)9 /6.&'(-6!KN<!PM1,-)3- 3.%(5);>(*+ (. />+3:* ,*'0%*++1 9*35*'+*9 B>%3().%':)(61'%9 5*+&)5'(.56 B'):>5* )% +>;R*3(+ ,)(- 4*56 +*4*5* ?@8A7 $%

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

$16;916F:8;7832;8WZ ->1:@:763;

E-* &5)%3)&': '3().% .B &-.+&-.9)*+(*5'+*<T )%-);)(.5+is to reduce inammation by inhibiting of the breakdownof intracellular cyclic AMP!PT1!PK7 $( )+ ' .%3* 9'):6 .5':/*9)3'().% ,)(- %. 9)5*3( ;5.%3-.9):'(.5 '3()4)(61 ':(-.>2-it has been shown to improve FEV

M )% &'()*%(+ (5*'(*9 ,)(-

+':/*(*5.: .5 ().(5.&)>/!PT. Roumilast reduces moderate

'%9 +*4*5* *D'3*5;'().%+ (5*'(*9 ,)(- 3.5()3.+(*5.)9+ ;6MK<!"L )% &'()*%(+ ,)(- 3-5.%)3 ;5.%3-)()+1 +*4*5* (. 4*56+*4*5* ?@8A1 '%9 ' -)+(.56 .B *D'3*5;'().%+!PP O&E:F8>58#). The effects on lung function are also seen whenroumilast is added to long-acting bronchodilators!PP1P!M O&E:F8>58 #). There are no direct comparison or add-on studies of roumilast and inhaled corticosteroids.8-.+&-.9)*+(*5'+*<T )%-);)(.5+ +-.>:9 ':,'6+ ;* >+*9 )%3./;)%'().% ,)(- '( :*'+( .%* :.%2<'3()%2 ;5.%3-.9):'(.57

%9B38;3 3CC3/1;< 8-.+&-.9)*+(*5'+*<T )%-);)(.5+ -'4*/.5* '94*5+* *BB*3(+ (-'% )%-':*9 /*9)3'().%+ B.5 ?@8A!PT

!PP7 E-* /.+( B5*C>*%( '94*5+* *BB*3(+ '5* %'>+*'1 5*9>3*9'&&*()(*1 ';9./)%': &')%1 9)'55-*'1 +:**& 9)+(>5;'%3*+1 '%9

-*'9'3-*7 =94*5+* *BB*3(+ :*9 (. )%35*'+*9 ,)(-95',': )%clinical trials from the group receiving roumilast. Adverse*BB*3(+ +**/ (. .33>5 *'5:6 9>5)%2 (5*'(/*%(1 '5* 5*4*5+);:*'%9 9)/)%)+- .4*5 ()/* ,)(- 3.%()%>*9 (5*'(/*%(7 $%3.%(5.::*9 +(>9)*+ '% '4*5'2* >%*D&:')%*9 ,*)2-( :.++ .B !02 -'+ ;**% +**% '%9 ,*)2-( /.%)(.5)%2 9>5)%2 (5*'(/*%(is advised as well as avoiding treatment with roumilastin underweight patients. Roumilast should also be usedwith caution in patients with depression. Roumilast and(-*.&-6::)%* +-.>:9 %.( ;* 2)4*% (.2*(-*57

,7183 $1234256A6?:5 %382748>7;

I6//.23;< Inuenza vaccination can reduce serious

)::%*++ O+>3- '+ :.,*5 5*+&)5'(.56 (5'3( )%B*3().%+ 5*C>)5)%2hospitalization!PV) and death in COPD patients!PZ<!V" O&E:F8>58 #). Vaccines containing killed or live,)%'3()4'(*9 4)5>+*+ '5* 5*3.//*%9*9!VM '+ (-*6 '5* /.5**BB*3()4* )% *:9*5:6 &'()*%(+ ,)(- ?@8A!V!7 E-* +(5')%+'5* '9R>+(*9 *'3- 6*'5 B.5 '&&5.&5)'(* *BB*3()4*%*++'%9 +-.>:9 ;* 2)4*% .%3* *'3- 6*'5 !VQ7 8%*>/.3.33':&.:6+'33-'5)9* 4'33)%* )+ 5*3.//*%9*9 B.5 ?@8A&'()*%(+ PK 6*'5+ '%9 .:9*51 '%9 ':+. )% 6.>%2*5 &'()*%(+with signicant comorbid conditions such as cardiac

8/16/2019 GOLD Report 2016


!P !"#$%&#'!() +&!(+,-

9)+*'+*!VT<!VP7 $% '99)().%1 (-)+ 4'33)%* -'+ ;**% +-.,% (.5*9>3* (-* )%3)9*%3* .B 3.//>%)(6<'3C>)5*9 &%*>/.%)' )%COPD patients younger than age 5 with an FEV

M _ T"L

&5*9)3(*9!VV O&E:F8>58 R).

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deciency and established emphysema may be candidatesB.5 ':&-'<M '%()(56&+)% '>2/*%('().% (-*5'&6 O&E:F8>58 !).[.,*4*51 (-)+ (-*5'&6 )+ 4*56 *D&*%+)4*1 )+ %.( '4'):';:* )%/.+( 3.>%(5)*+1 '%9 )+ %.( 5*3.//*%9*9 B.5 &'()*%(+ ,)(-COPD that is unrelated to alpha-1 antitrypsin deciency.

%21.G.01./;< $% .:9*5 +(>9)*+ &5.&-6:'3()31 3.%()%>.>+ >+*.B '%();).()3+ ,'+ +-.,% (. -'4* %. *BB*3( .% (-* B5*C>*%36.B *D'3*5;'().%+ )% ?@8A!VZ<!Z"1 '%9 ' +(>96 (-'( *D'/)%*9the efcacy of chemoprophylaxis undertaken in winter/.%(-+ .4*5 ' &*5).9 .B K 6*'5+ 3.%3:>9*9 (-'( (-*5* ,'+no benet!ZM7 =:(-.>2- +(>9)*+ -'4* +-.,% +./* *BB*3(+.B '%();).()3+ .% *D'3*5;'().% 5'(*!Z!1!ZQ1 (-* 5.:* .B (-)+treatment is unclear. A trial of daily azithromycin showed

efcacy on exacerbation end-points with little evidence.B (5*'(/*%( *BB*3( '/.%2 3>55*%( +/.0*5+KNQH -.,*4*51(5*'(/*%( )+ %.( 5*3.//*%9*9 ;*3'>+* .B '% >%B'4.5';:*balance between benets and side effects!ZT7 E->+1(-* >+* .B '%();).()3+1 .(-*5 (-'% B.5 (5*'()%2 )%B*3().>+*D'3*5;'().%+ .B ?@8A '%9 .(-*5 ;'3(*5)': )%B*3().%+1 )+3>55*%(:6 %.( )%9)3'(*9!ZK1!ZP O&E:F8>58 R).

D:/05E1./ K7:/0L.231./M 7:/083>:56108N 629 %21.0F.9621 %>321; K67G80F05M 3890;13.23M/68G0/E;13.23M .09.26139 >5E/3805M ,A6/31E5/E;13.23N<E-* 5*2>:'5 >+* .B />3.:6()3+ )% ?@8A -'+ ;**% *4':>'(*9)% ' %>/;*5 .B :.%2<(*5/ +(>9)*+ ,)(- 3.%(5.4*5+)':5*+>:(+!ZV<!ZN7 =:(-.>2- ' B*, &'()*%(+ ,)(- 4)+3.>+ +&>(>/

may benet from mucolytics!N"1!NM, the overall benets+**/ (. ;* 4*56 +/'::H (-* ,)9*+&5*'9 >+* .B (-*+*'2*%(+ 3'%%.( ;* 5*3.//*%9*9 '( &5*+*%( O&E:F8>58J). Drugs like N-acetylcysteine may have antioxidant*BB*3(+1 :*'9)%2 (. +&*3>:'().% (-'( (-*+* /*9)3'().%+3.>:9 -'4* ' 5.:* )% (-* (5*'(/*%( .B &'()*%(+ ,)(- 5*3>55*%(*D'3*5;'().%+!N!<!NK1KP! O&E:F8>58 R). In patients treated,)(- '%9 ,)(-.>( )%-':*9 3.5()3.+(*5.)9+1 -)2- 9.+*+of N-acetylcysteine signicantly reduced exacerbation5'(*+1 ;>( .%:6 )% a@\A +('2* ! &'()*%(+KNT7 E-*5* )++./* *4)9*%3* (-'( )% ?@8A &'()*%(+ %.( 5*3*)4)%2)%-':*9 3.5()3.+(*5.)9+1 (5*'(/*%( ,)(- />3.:6()3+ +>3-'+ 3'5;.36+(*)%* '%9 I<'3*(6:36+(*)%* /'6 5*9>3*

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(77:2083>:56108; K.77:20;1.7:56108;M.77:20709:56108;N< J(>9)*+ >+)%2 '% )//>%.5*2>:'(.5)% ?@8A 5*&.5( ' 9*35*'+* )% (-* +*4*5)(6 '%9 B5*C>*%36.B *D'3*5;'().%+!NZ1!NN7 [.,*4*51 '99)().%': +(>9)*+ (.*D'/)%* (-* :.%2<(*5/ *BB*3(+ .B (-)+ (-*5'&6 '5* 5*C>)5*9H'( &5*+*%(1 )(+ 5*2>:'5 >+* 3'%%.( ;* 5*3.//*%9*9Q""7

%21.1:;;.B3;< ?.>2-1 ':(-.>2- +./*()/*+ ' (5.>;:*+./*symptom in COPD, has a signicant protective roleQ"M7 E-*5*2>:'5 >+* .B '%()(>++)4*+ )+ %.( 5*3.//*%9*9 )% +(';:*?@8A O&E:F8>58 J).

I6;09.56108;< E-* ;*:)*B (-'( &>:/.%'56 -6&*5(*%+).% )%

?@8A )+ '++.3)'(*9 ,)(- ' &..5*5 &5.2%.+)+ -'+ &5.4.0*9/'%6 '((*/&(+ (. 5*9>3* 5)2-( 4*%(5)3>:'5 'B(*5:.'91)%35*'+* 3'59)'3 .>(&>(1 '%9 )/&5.4* .D62*% 9*:)4*56 '%9tissue oxygenation. Many agents have been evaluated,)%3:>9)%2 )%-':*9 %)(5)3 .D)9*1 ;>( (-* 5*+>:(+ -'4* ;**%>%)B.5/:6 9)+'&&.)%()%27 $% &'()*%(+ ,)(- ?@8A1 )% ,-./-6&.D*/)' )+ 3'>+*9 &5)/'5):6 ;6 4*%():'().%<&*5B>+).%/)+/'(3-)%2 5'(-*5 (-'% ;6 )%35*'+*9 )%(5'&>:/.%'56shunt (as in noncardiogenic pulmonary edema), inhaled%)(5)3 .D)9* 3'% ,.5+*% 2'+ *D3-'%2* ;*3'>+* .B ':(*5*9-6&.D)3 5*2>:'().% .B 4*%():'().%<&*5B>+).% ;':'%3*Q"!1Q"Q7E-*5*B.5*1 ;'+*9 .% (-* '4'):';:* *4)9*%3*1 %)(5)3 .D)9*)+ 3.%(5')%9)3'(*9 )% +(';:* ?@8A7 \)0*,)+*1 2>)9*:)%*+.% (-* (5*'(/*%( .B &>:/.%'56 -6&*5(*%+).% 9. %.(

5*3.//*%9 (-* >+* .B *%9.(-*:)>/</.9>:'()%2 '2*%(+B.5 (-* (5*'(/*%( .B &>:/.%'56 -6&*5(*%+).% '++.3)'(*9with COPD until data on their safety and efcacy in this3.%9)().% '5* '4'):';:*Q"T7

,68/01./; K7084=.23N7 @5': '%9 &'5*%(*5': .&).)9+ '5**BB*3()4* B.5 (5*'()%2 96+&%*' )% ?@8A &'()*%(+ ,)(- 4*56severe disease. There is insufcient data to concludewhether nebulized opioids are effectiveQ"K7 [.,*4*51 +./*3:)%)3': +(>9)*+ +>22*+( (-'( /.5&-)%* >+*9 (. 3.%(5.:dyspnea may have serious adverse effects and its benets/'6 ;* :)/)(*9 (. ' B*, +*%+)()4* +>;R*3(+Q"P<QM"7

+1=38;< Nedocromil and leukotriene modiers have not;**% '9*C>'(*:6 (*+(*9 )% ?@8A &'()*%(+ '%9 3'%%.(

be recommended. There was no evidence of benet'%9 +./* +./* *4)9*%3* .B -'5/ O/':)2%'%36 '%9pneumonia)from an anti-TNF-alpha antibody (iniximab)(*+(*9 )% /.9*5'(* (. +*4*5* ?@8AQMM7 E-*5* )+ %.*4)9*%3* B.5 (-* *BB*3()4*%*++ .B -*5;': /*9)3)%*+ )%(5*'()%2 ?@8AQM! '%9 .(-*5 ':(*5%'()4* -*':)%2 /*(-.9+(e.g., acupuncture and homeopathy) have not beenadequately tested. There is evidence that sildenal9.*+ %.( )/&5.4* (-* 5*+>:(+ .B 5*-';):)('().% )% &'()*%(+,)(- ?@8A '%9 /.9*5'(*:6 )%35*'+*9 &>:/.%'56 '5(*56&5*++>5*KNK7 $% >%+*:*3(*9 &'()*%(+ (-*5* )+ %. *4)9*%3*(-'( +>&&:*/*%('().% .B 4)('/)% A -'+ ' &.+)()4* )/&'3( .%*D'3*5;'().%+KNP7

.,.W$"#'H#!,\,I-! %"&'#$-&/

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8/16/2019 GOLD Report 2016


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'9*C>'(*:6 '995*++*9 ;6 /*9)3': (-*5'&6 B.5 ?@8A1

)%3:>9)%2 *D*53)+* 9*<3.%9)().%)%21 5*:'()4* +.3)': )+.:'().%1altered mood states (especially depression), muscle wasting,'%9 ,*)2-( :.++7 8>:/.%'56 5*-';):)('().% -'+ ;**% 3'5*B>::6*4':>'(*9 )% ' :'52* %>/;*5 .B 3:)%)3': (5)':+ '%9 +-.,%(. )%35*'+* &*'0 ,.50:.'91 &*'0 .D62*% 3.%+>/&().%1'%9 *%9>5'%3* ()/*QMK. Benets have been reported from5*-';):)('().% &5.25'/+ 3.%9>3(*9 )% )%&'()*%(1 .>(&'()*%(1 '%9-./* +*(()%2+QMK1QMPH 3.%+)9*5'().%+ .B 3.+( '%9 '4'):';):)(6/.+( .B(*% 9*(*5/)%* (-* 3-.)3* .B +*(()%27 E-* 4'5).>+benets of pulmonary rehabilitation are summarized in %2@A8(B[QMQ1QMT1QMV<Q!"7 [.,*4*5 (-* )%35*'+*9 *D*53)+* 3'&'3)(6/'6 %.( %*3*++'5):6 (5'%+:'(* )%(. )%35*'+*9 9'):6 &-6+)3':'3()4)(6KPQ7

E-* /)%)/>/ :*%2(- .B '% *BB*3()4* 5*-';):)('().% &5.25'/)+ P ,**0+H (-* :.%2*5 (-* &5.25'/ 3.%()%>*+1 (-* /.5**BB*3()4* (-* 5*+>:(+Q!M<Q!Q7 [.,*4*51 '+ 6*(1 %. *BB*3()4*&5.25'/ -'+ ;**% 9*4*:.&*9 (. /')%(')% (-* *BB*3(+.4*5 ()/*Q!T. Many physicians advise patients unable to&'5()3)&'(* )% ' +(5>3(>5*9 &5.25'/ (. *D*53)+* .% (-*)5 .,%(e.g., walking 20 minutes daily). The benets of this general'94)3* -'4* %.( ;**% (*+(*91 ;>( ;*3'>+* .;+*54'().%':studies have indicated signicant benets of physical'3()4)(6Q!K1Q!P1 '%9 ;*3'>+* &-6+)3': '3()4)(6 )+ 2..9 B.5 +./'%6 .(-*5 5*'+.%+1 )( )+ -)2-:6 5*'+.%';:* (. .BB*5 +>3-'94)3* (. &'()*%(+ )B ' B.5/': &5.25'/ )+ %.( '4'):';:*7

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,':0)%2 (*+(+ .BB*5 ' 3./&5./)+*b (-*6 &5.4)9* /.5*3./&:*(* )%B.5/'().% (-'% '% *%()5*:6 +*:B<&'3*9 (*+(1 ;>( '5*

+)/&:*5 (. &*5B.5/ (-'% ' (5*'9/):: (*+(MKQ7

FD*53)+* (5')%)%2 5'%2*+ )% B5*C>*%36 B5./ 9'):6 (. ,**0:61 )%

9>5'().% B5./ M" /)%>(*+ (. TK /)%>(*+ &*5 +*++).%1 '%9 )%

)%(*%+)(6 B5./ K"L &*'0 .D62*% 3.%+>/&().% OS@! max) to

/'D)/>/ (.:*5'(*9!KQ7 E-* .&()/>/ :*%2(- B.5 '% *D*53)+*

program has not been investigated in randomized controlled

(5)':+ ;>( /.+( +(>9)*+ )%4.:4)%2 B*,*5 (-'% !Z *D*53)+*

+*++).%+ +-., )%B*5).5 5*+>:(+ 3./&'5*9 (. (-.+* ,)(- :.%2*5

(5*'(/*%( &*5).9+Q!V7 $% &5'3()3*1 (-* :*%2(- 9*&*%9+ .% (-*

5*+.>53*+ '4'):';:* '%9 >+>'::6 5'%2*+ B5./ T (. M" ,**0+1

,)(- :.%2*5 &5.25'/+ 5*+>:()%2 )% :'52*5 *BB*3(+ (-'% +-.5(*5&5.25'/+QMZ7

$% /'%6 &5.25'/+1 *+&*3)'::6 (-.+* >+)%2 +)/&:* 3.55)9.5

*D*53)+* (5')%)%21 (-* &'()*%( )+ *%3.>5'2*9 (. ,':0 (. '

+6/&(./<:)/)(*9 /'D)/>/1 5*+(1 '%9 (-*% 3.%()%>* ,':0)%2

>%(): !" /)%>(*+ .B *D*53)+* -'4* ;**% 3./&:*(*97 X-*5*

&.++);:*1 *%9>5'%3* *D*53)+* (5')%)%2 (. P"<Z"L .B (-*

+6/&(./<:)/)(*9 /'D)/>/ )+ &5*B*55*97 F%9>5'%3* (5')%)%2

3'% ;* '33./&:)+-*9 (-5.>2- 3.%()%>.>+ .5 )%(*54': *D*53)+*

&5.25'/+7 E-* :'((*5 )%4.:4* (-* &'()*%( 9.)%2 (-* +'/*

(.(': ,.50 ;>( 9)4)9*9 )%(. ;5)*B*5 &*5).9+ .B -)2-<)%(*%+)(6

*D*53)+*1 ,-)3- )+ >+*B>: ,-*% &*5B.5/'%3* )+ :)/)(*9 ;6

.(-*5 3./.5;)9)()*+Q!Z1Q!N7 ^+* .B ' +)/&:* ,-**:*9 ,':0)%2')9 +**/+ (. )/&5.4* ,':0)%2 9)+('%3* '%9 5*9>3*+

;5*'(-:*++%*++ )% +*4*5*:6 9)+';:*9 ?@8A &'()*%(+QQ"<QQ!7

@(-*5 '&&5.'3-*+ (. )/&5.4)%2 .>(3./*+ +>3- '+ >+* .B

.D62*% 9>5)%2 *D*53)+*QQQ1 *D*53)+)%2 ,-):* ;5*'(-)%2 -*:).D

2'+ /)D(>5*+QQT1 .5 >%:.'9)%2 (-* 4*%():'(.5 />+3:*+ ,-):*

*D*53)+)%2 5*/')% *D&*5)/*%(': '( &5*+*%(7

J./* &5.25'/+ ':+. )%3:>9* >&&*5 :)/; *D*53)+*+1 >+>'::6

)%4.:4)%2 '% >&&*5 :)/; *52./*(*5 .5 5*+)+()4* (5')%)%2 ,)(-

weights. There are no randomized clinical trial data to

+>&&.5( (-* 5.>()%* )%3:>+).% .B (-*+* *D*53)+*+1 ;>( (-*6 /'6

;* -*:&B>: )% &'()*%(+ ,)(- 3./.5;)9)()*+ (-'( 5*+(5)3( .(-*5

B.5/+ .B *D*53)+* '%9 (-.+* ,)(- *4)9*%3* .B 5*+&)5'(.56

/>+3:* ,*'0%*++QQK7 $% 3.%(5'+(1 )%+&)5'(.56 />+3:* (5')%)%2

appears to provide additional benets when included in a

3./&5*-*%+)4* &>:/.%'56 5*-';):)('().% &5.25'/QQP<QQZ7 E-*

'99)().% .B >&&*5 :)/; *D*53)+*+ .5 .(-*5 +(5*%2(- (5')%)%2 (.

'*5.;)3 (5')%)%2 )+ *BB*3()4* )% )/&5.4)%2 +(5*%2(-1 ;>( 9.*+ %.(

)/&5.4* C>':)(6 .B :)B* .5 *D*53)+* (.:*5'%3*QQN7

The following points summarize current knowledge of

Table .5. Benets of Pulmonary Rehabilitation in COPD

• P3+0%8*. *<*0(-.* ('+'(-1? N&E:F8>58 #Q"

• \*)4(*. 1/* +*0(*-8*) -,1*,.-1? %; &0*'1/5*..,*.. N&E:F8>58 #Q"

• P3+0%8*. /*'51/70*5'1*) I4'5-1? %; 5-;* _&E:F8>58 #Q"

• \*)4(*. 1/* ,43&*0 %; /%.+-1'5-@'1-%,. ',) )'?. -, 1/* /%.+-1'5

N&E:F8>58 #Q"

• Reduces anxiety and depression associated with COPD (&E:F8>58 #Q"

• H10*,61/ ',) *,)40',(* 10'-,-,6 %; 1/* 4++*0 5-3&. -3+0%8*. '03

;4,(1-%, N&E:F8>58 RQ"

• Benets extend well beyond the immediate period of trainingN&E:F8>58 RQ"

• P3+0%8*. .408-8'5 N&E:F8>58 RQ"

• Respiratory muscle training can be benecial, especially when(%3&-,*) 2-1/ 6*,*0'5 *<*0(-.* 10'-,-,6 N&E:F8>58 !Q"

• P3+0%8*. 0*(%8*0? ';1*0 /%.+-1'5-@'1-%, ;%0 ', *<'(*0&'1-%, D9A

N&E:F8>58 #Q"

• :,/',(*. 1/* *;;*(1 %; 5%,67'(1-,6 &0%,(/%)-5'1%0. N&E:F8>58 RQ"

8/16/2019 GOLD Report 2016


!Z !"#$%&#'!() +&!(+,-

3.%+)9*5'().%+ )/&.5('%( )% 3-..+)%2 &'()*%(+ B.5 &>:/.%'56

5*-';):)('().%b

O:2/1.0265 ;161:;P Benets have been seen in patients

,)(- ' ,)9* 5'%2* .B 9)+';):)(61 ':(-.>2- (-.+* ,-. '5* 3-')5<

;.>%9 '&&*'5 :*++ :)0*:6 (. 5*+&.%9 *4*% (. -./* 4)+)()%2

&5.25'/+QT" O&E:F8>58 R).

-3B38.1E 0C 9E;4236P Stratication by breathlessness

intensity using the mMRC questionnaire may be helpful in

selecting patients most likely to benet from rehabilitation.

Those with mMRC grade 4 dyspnea may not benetQT"

O&E:F8>58 R).

D01.B61.02P J*:*3()%2 -)2-:6 /.()4'(*9 &'5()3)&'%(+ )+

*+&*3)'::6 )/&.5('%( )% (-* 3'+* .B .>(&'()*%( &5.25'/+QTM7

A*&5*++*9 /..9 )+ ' 5)+0 B'3(.5 B.5 %.%<3./&:*().% .B

5*-';):)('().% &5.25'/+P!!7

-70L.2> ;161:;P E-*5* )+ %. *4)9*%3* (-'( +/.0*5+ ,)::

benet less than nonsmokers, although some suggest that3.%()%>)%2 +/.0*5+ '5* :*++ :)0*:6 (. 3./&:*(* &>:/.%'56

5*-';):)('().% &5.25'/+ (-'% %.%+/.0*5+QTM O&E:F8>58 R).

#9:/61.02< Most pulmonary rehabilitation programs include

'% *9>3'().%': 3./&.%*%(7 E-* (.&)3+ (-'( +**/ /.+(

'&&5.&5)'(* B.5 '% *9>3'().% &5.25'/ )%3:>9*b +/.0)%2

3*++'().%H ;'+)3 )%B.5/'().% ';.>( ?@8AH 2*%*5': '&&5.'3-

to therapy and specic aspects of medical treatment; self-

management skills; strategies to help minimize dyspnea;

'94)3* ';.>( ,-*% (. +**0 -*:&H 9*3)+).%</'0)%2 9>5)%2

*D'3*5;'().%+H '%9 '94'%3* 9)5*3()4*+ '%9 *%9<.B<:)B* )++>*+7

E-* )%(*%+)(6 '%9 3.%(*%( .B (-*+* *9>3'().%': /*++'2*++-.>:9 4'56 9*&*%9)%2 .% (-* +*4*5)(6 .B (-* &'()*%(G+

disease, although the specic contributions of education to

(-* )/&5.4*/*%(+ +**% 'B(*5 &>:/.%'56 5*-';):)('().% 5*/')%

>%3:*'57 J(>9)*+ )%9)3'(* (-'( &'()*%( *9>3'().% ':.%* 9.*+

%.( )/&5.4* *D*53)+* &*5B.5/'%3* .5 :>%2 B>%3().%QT!<QTK1 ;>( )(

3'% &:'6 ' 5.:* )% )/&5.4)%2 +0)::+1 ';):)(6 (. 3.&* ,)(- )::%*++1

'%9 -*':(- +('(>+QTP7 E-*+* .>(3./*+ '5* %.( (5'9)().%'::6

/*'+>5*9 )% 3:)%)3': (5)':+1;>( (-*6 /'6 ;* /.+( )/&.5('%( )%

?@8A ,-*5* *4*% &-'5/'3.:.2)3 )%(*54*%().%+ 2*%*5'::6

confer only a small benet in terms of lung function.

8'()*%(+ ,)(- +*4*5* ?@8A .B(*% *D&5*++ (-* 9*+)5*

(. 9)+3>++ *%9<.B<:)B* 3'5* ,)(- 3:)%)3)'%+1 ;>( (-*+*

3.%4*5+'().%+ 5'5*:6 .33>5 )% 3:)%)3': &5'3()3*7 J)/&:*1

+(5>3(>5*9 '&&5.'3-*+ (. B'3):)('(* (-*+* 3.%4*5+'().%+ /'6

-*:& (. )/&5.4* (-* .33>55*%3* '%9 C>':)(6 .B 3.//>%)3'().%

B5./ (-* &'()*%(+G &*5+&*3()4*K!K7 $% &'5()3>:'51 &'()*%(+ ,)(- '

3-5.%)3 :)B*<:)/)()%2 )::%*++ :)0* ?@8A +-.>:9 ;* )%B.5/*9 (-'(1

+-.>:9 (-*6 ;*3./* 35)()3'::6 )::1 (-*6 .5 (-*)5 B'/):6 /*/;*5+

/'6 ;* )% ' &.+)().% ,-*5* (-*6 ,.>:9 %**9 (. 9*3)9*

whether a) a course of intensive care is likely to achieve their

personal goals of care, and b) they are willing to accept the

;>59*%+ .B +>3- (5*'(/*%(7 ?.//>%)3'().% ';.>( *%9<.B<:)B*

3'5* '%9 '94'%3* 3'5* &:'%%)%2 2)4*+ &'()*%(+ (-* .&&.5(>%)(6

(. /'0* )%B.5/*9 9*3)+).%+ ';.>( (-* 0)%9 .B 3'5* (-*6 ,'%(

'%9 *%+>5* (-'( (-*)5 B'/):6 '%9 3:)%)3)'%+ >%9*5+('%9 (-*)5

4':>*+1 2.':+1 '%9 &*5+&*3()4*+K!P7 ?:)%)3)'%+ +-.>:9 9*4*:.&

'%9 )/&:*/*%( /*(-.9+ (. -*:& &'()*%(+ '%9 (-*)5 B'/):)*+(. /'0* )%B.5/*9 3-.)3*+ (-'( '5* 3.%+)+(*%( ,)(- &'()*%(+G

4':>*+7 J>3- /*(-.9+ -'4* (-* &.(*%()': (. )/&5.4* (-*

C>':)(6 .B 3'5* '%9 +)/>:('%*.>+:6 /'6 3.%(5);>(* (. *BB.5(+

(. 5*9>3* -*':(- 3'5* 3.+(+ ;6 *%+>5)%2 &'()*%(+ 5*3*)4* 3'5*

3.%+)+(*%( ,)(- (-*)5 2.':+ '%9 4':>*+K!V1K!Z7

%;;3;;7321 629 O0550QA:4< W'+*:)%* '%9 .>(3./*'++*++/*%(+ .B *'3- &'5()3)&'%( )% ' &>:/.%'565*-';):)('().% &5.25'/ +-.>:9 ;* /'9* (. C>'%()B6 )%9)4)9>':2')%+ '%9 ('52*( '5*'+ B.5 )/&5.4*/*%(7 =++*++/*%(++-.>:9 )%3:>9*b

•A*('):*9 -)+(.56 '%9 &-6+)3': *D'/)%'().%

• Measurement of post-bronchodilator spirometry

• =++*++/*%( .B *D*53)+* 3'&'3)(6

• Measurement of health status and impact ofbreathlessness (e.g., CAT and mMRC scales)

• =++*++/*%( .B )%+&)5'(.56 '%9 *D&)5'(.56 />+3:*strength and lower limb strength (e.g., quadriceps) in&'()*%(+ ,-. +>BB*5 B5./ />+3:* ,'+()%2

The rst two assessments are important for establishing entry+>)(';):)(6 '%9 ;'+*:)%* +('(>+ ;>( '5* %.( >+*9 )% .>(3./*'++*++/*%(7 E-* :'+( (-5** '++*++/*%(+ '5* ;'+*:)%* '%9

.>(3./* /*'+>5*+7 J*4*5': 9*('):*9 C>*+().%%')5*+ B.5'++*++)%2 -*':(- +('(>+ '5* '4'):';:*1 )%3:>9)%2 +./* (-'(are specically designed for patients with respiratory diseaseO*7271 )24.563 $7/86490.4: ;6/79/7 <=7/06.559647>?@ A -0BC7.4D7 $7/86490.4: <=7/06.559647?EF A )24.563 +G/04=306H7&=IJ.594: ;6/79/7 %//7//J750 !7/0 K>E), and there is)%35*'+)%2 *4)9*%3* (-'( (-*+* C>*+().%%')5*+ /'6 ;* >+*B>:)% ' 3:)%)3': +*(()%27 [*':(- +('(>+ 3'% ':+. ;* '++*++*9 ;62*%*5)3 C>*+().%%')5*+1 +>3- '+ (-* L7M639I +=03.J7/ -0=M:-2.40 N.4J O-N?@ )?EP 1 (. *%';:* 3./&'5)+.% .B C>':)(6 .B :)B*)% 9)BB*5*%( 9)+*'+*+7 E-* "./8609I %5Q670: 95M ;7847//6.5-39I7 O"%;-R?ES '%9 (-* &46J94: )947 #H9I=906.5 .T L7509I;6/.4M74/ O&$(L#1L;R &906750 <=7/06.559647QK" -'4* ;**%

used to improve identication and treatment of anxious and9*&5*++*9 &'()*%(+7

,:18.1.0265 ;:44081< \.,<(.</.9*5'(* C>':)(6 *4)9*%3*suggests that nutritional support promotes signicant gain)% ,*)2-( '%9 B'(<B5** /'++ '/.%2 &'()*%(+ ,)(- ?@8A1especially if malnourished. In addition, signicantly25*'(*5 3-'%2*+ B5./ ;'+*:)%* -'4* ;**% .;+*54*9 )%+>&&:*/*%(*9 &'()*%(+ B.5 +)D</)%>(* ,':0 (*+(1 5*+&)5'(.56muscle strength and (only in malnourished patients) overall

8/16/2019 GOLD Report 2016


!"#$%&#'!() +&!(+,- !N

[Uc.\ '+ /*'+>5*9 ;6 JaUc7 8.+)()4* *BB*3(+ -'4* ;**%.;+*54*9 ,-*% %>(5)().%': +>&&:*/*%('().% )+ &5.&.+*9':.%* .5 '+ '% '9R>%3( (. *D*53)+* (5')%)%27 E-* .&()/':'/.>%( '%9 9>5'().% .B +>&&:*/*%('().% '5* %.( 3:*'5:6*+(';:)+-*9KPT7

,%"&' %'&#%H&.%/,c]?8> %18329]

The long-term administration of oxygen ( 15 hours per day)(. &'()*%(+ ,)(- 3-5.%)3 5*+&)5'(.56 B'):>5* -'+ ;**% +-.,% (.)%35*'+* +>54)4': )% &'()*%(+ ,)(- +*4*5* 5*+()%2 -6&.D*/)'QKN

O&E:F8>58 R). Long-term oxygen therapy is indicated for&'()*%(+ ,-. -'4*b

• 8'@! at or below 7.3 kPa (55 mmHg) or SaO

! '( .5

below %, with or without hypercapnia conrmed twice.4*5 ' (-5** ,**0 &*5).9 O&E:F8>58 R); or

• 8'@! between 7.3 kPa (55 mmHg) and .0 kPa(0 mmHg), or SaO

! .B ZZL1 )B (-*5* )+ *4)9*%3* .B

&>:/.%'56 -6&*5(*%+).%1 &*5)&-*5': *9*/' +>22*+()%23.%2*+()4* 3'59)'3 B'):>5*1 .5 &.:636(-*/)' O-*/'(.35)( d55%) (&E:F8>58 J).

= 9*3)+).% ';.>( (-* >+* .B :.%2<(*5/ .D62*% +-.>:9 ;*;'+*9 .% (-* 5*+()%2 8'@

! .5 +'(>5'().% 4':>*+ 5*&*'(*9

(,)3* .4*5 (-5** ,**0+ )% (-* +(';:* &'()*%(7 ?>55*%( 9'('9. %.( +>&&.5( (-* >+* .B '/;>:'(.56 .D62*% )% &'()*%(&.&>:'().%+ (-'( 9. %.( /**( (-* ';.4* 35)(*5)'QP"7

=:(-.>2- ')5 (5'4*: )+ +'B* B.5 /.+( &'()*%(+ ,)(- 3-5.%)3

5*+&)5'(.56 B'):>5* ,-. '5* .% :.%2<(*5/ .D62*% (-*5'&6K!N

1patients should ideally be able to maintain an in-ight PaO!

of at least .7 kPa (50 mmHg). Studies indicate that this can;* '3-)*4*9 )% (-.+* ,)(- /.9*5'(* (. +*4*5* -6&.D*/)''( +*' :*4*: ;6 +>&&:*/*%('56 .D62*% '( Q \Y/)% ;6 %'+':3'%%>:'* .5 QML ;6 S*%(>5) B'3*/'+0QPM7 E-.+* ,)(- '5*+()%2 8'@

! at sea level .3 kPa (70 mmHg) are likely to

be safe to y without supplementary oxygenQP!1QPQ1 ':(-.>2-it is important to emphasize that a resting PaO

! d N7Q 08'

(70 mmHg) at sea level does not exclude the development.B +*4*5* -6&.D*/)' ,-*% (5'4*::)%2 ;6 ')5 O&E:F8>58 !).?'5*B>: 3.%+)9*5'().% +-.>:9 ;* 2)4*% (. '%6 3./.5;)9)(6(-'( /'6 )/&')5 .D62*% 9*:)4*56 (. ()++>*+ O*7271 3'59)'3impairment, anemia). Also, walking along the aisle may&5.B.>%9:6 '225'4'(* -6&.D*/)'QPT7

Y8>7:A2763] /K99637

Non-invasive ventilation (NIV) is increasingly used inpatients with stable very severe COPD. Randomized3.%(5.::*9 (5)':+ &5.4)9* 3.%(5'9)3(.56 5*+>:(+ 5*2'59)%2 (-*clinical benets of long-term NIV in patients with COPD and3-5.%)3 -6&*53'&%)'1 *+&*3)'::6 )% (*5/+ .B -*':(- +('(>+

'%9 +>54)4':KNV<KNN. Thus, there is insufcient evidence toB.5/>:'(* 5*3.//*%9'().%+7 E-* 3./;)%'().% .B I$S ,)(-:.%2<(*5/ .D62*% (-*5'&6 /'6 ;* .B +./* >+* )% ' +*:*3(*9+>;+*( .B &'()*%(+1 &'5()3>:'5:6 )% (-.+* ,)(- &5.%.>%3*99'6()/* -6&*53'&%)'QPK7 $( /'6 )/&5.4* +>54)4': ;>( 9.*+%.( )/&5.4* C>':)(6 .B :)B*QPK7 [.,*4*51 )% &'()*%(+ ,)(- ;.(-COPD and obstructive sleep apnea there are clear benets

from continuous positive airway pressure (CPAP) in both+>54)4': '%9 5)+0 .B -.+&)(': '9/)++).%QPP7

/K3?:52A %382748>7;

R:2> I05:73 $39:/1.02 -:8>38E KRI$-N7 \SUJ )+ '+>52)3': &5.3*9>5* )% ,-)3- &'5(+ .B (-* :>%2 '5* 5*+*3(*9 (.reduce hyperinationQPV1 /'0)%2 5*+&)5'(.56 />+3:*+ /.5**BB*3()4* &5*++>5* 2*%*5'(.5+ ;6 )/&5.4)%2 (-*)5 /*3-'%)3':efciency (as measured by length/tension relationship,curvature of the diaphragm, and area of apposition)QPZ1QPN7$% '99)().%1 \SUJ )%35*'+*+ (-* *:'+()3 5*3.): &5*++>5*of the lung and thus improves expiratory ow rates and

5*9>3*+ *D'3*5;'().%+QV"

7 E-* '94'%('2* .B +>52*56 .4*5medical therapy is more signicant among patients with&5*9./)%'%(:6 >&&*5<:.;* */&-6+*/' '%9 :., *D*53)+*3'&'3)(6 &5).5 (. (5*'(/*%(7 = &5.+&*3()4* *3.%./)3 '%':6+)+)%9)3'(*9 (-'( \SUJ )+ 3.+(:6 5*:'()4* (. -*':(-<3'5* &5.25'/+%.( )%3:>9)%2 +>52*56QVM7 $% 3.%(5'+( (. /*9)3': (5*'(/*%(1\SUJ -'+ ;**% 9*/.%+(5'(*9 (. 5*+>:( )% )/&5.4*9 +>54)4':(54% vs. 3.7%) in severe emphysema patients with upper-:.;* */&-6+*/' '%9 :., &.+(<5*-';):)('().% *D*53)+*3'&'3)(6QV! O&E:F8>58 #). In similar patients with high post-&>:/.%'56 5*-';):)('().% *D*53)+* 3'&'3)(6 %. 9)BB*5*%3*)% +>54)4': ,'+ %.(*9 'B(*5 \SUJ1 ':(-.>2- -*':(-<5*:'(*9C>':)(6 .B :)B* '%9 *D*53)+* 3'&'3)(6 )/&5.4*97 \SUJ -'+;**% 9*/.%+(5'(*9 (. 5*+>:( )% -)2-*5 /.5(':)(6 (-'% /*9)3':management in severe emphysema patients with an FEV

M

≤ 20% predicted and either homogeneous emphysema on-)2- 5*+.:>().% 3./&>(*9 (./.25'&-6 .5 ' A\

?@ ≤ 20%

&5*9)3(*9QVQ7

?802/=0;/04./ R:2> I05:73 $39:/1.02 K?RI$N< $%' &.+(<-.3 '%':6+)+1 W\SU )% ?@8A &'()*%(+ ,)(- +*4*5*airow limitation (FEV

M 15-45% predicted), heterogeneous

emphysema on CT scan, and hyperination (TLC 100%and RV 150% predicted) has been demonstrated to result)% /.9*+( )/&5.4*/*%(+ )% :>%2 B>%3().%1 *D*53)+* (.:*5'%3*1'%9 +6/&(./+ '( (-* 3.+( .B /.5* B5*C>*%( *D'3*5;'().%+.B ?@8A1 &%*>/.%)'1 '%9 -*/.&(6+)+ 'B(*5 )/&:'%('().%QVT7

Additional data are required to dene the optimal technique '%9 &'()*%( &.&>:'().%7 J*4*5': %.% +>52)3': ;5.%3-.+3.&)3:>%2 4.:>/* 5*9>3().% (*3-%)C>*+ O*7271 4':4*+1 2:>*+1coils) are being studied. However, available evidenceis insufcient to determine their benet-risk ratios, cost-*BB*3()4*%*++ '%9 &.++);:* 5.:*+ )% (-* +(5'(*26 .B 3'5* B.5&'()*%(+ ,)(- &5*9./)%'%( */&-6+*/'7 E-*+* (*3-%)C>*++-.>:9 %.( ;* >+*9 .>(+)9* 3:)%)3': (5)':+ >%(): /.5* 9'(' '5*'4'):';:*7

8/16/2019 GOLD Report 2016


Q" !"#$%&#'!() +&!(+,-

R:2> !862;4562161.02< $% '&&5.&5)'(*:6 +*:*3(*9 &'()*%(+,)(- 4*56 +*4*5* ?@8A1 :>%2 (5'%+&:'%('().% -'+ ;**%+-.,% (. )/&5.4* C>':)(6 .B :)B* '%9 B>%3().%': 3'&'3)(6QVK1QVP7 E-* 3.//.% 3./&:)3'().%+ +**% )% ?@8A &'()*%(+ 'B(*5:>%2 (5'%+&:'%('().%1 '&'5( B5./ &.+(<.&*5'()4* /.5(':)(61'5* '3>(* 5*R*3().%1 ;5.%3-).:)()+ .;:)(*5'%+1 .&&.5(>%)+()3infections such as CMV, fungal ()95M6M9A %/874D6II=/A)4:80.3.33=/A &57=J.3:/06/) or bacterial (&/7=M.J.59/A-0982:I.3.33=/ /87367/) infections, and lymphoproliferative9)+*'+*QVV7 \>%2 (5'%+&:'%('().% )+ :)/)(*9 ;6 (-* +-.5('2*.B 9.%.5 .52'%+ '%9 3.+(+7 ?5)(*5)' B.5 5*B*55': B.5 :>%2(5'%+&:'%('().% )%3:>9* ?@8A ,)(- ' W@AF )%9*D *D3**9)%2K7 U*3.//*%9*9 35)(*5)' B.5 :)+()%2 )%3:>9* ' W@AF )%9*D .BV<M" '%9 '( :*'+( .%* .B (-* B.::.,)%2b -)+(.56 .B *D'3*5;'().%'++.3)'(*9 ,)(- '3>(* -6&*53'&%)' e8'?@

! d P7V 08' OK"

mmHg); pulmonary hypertension, cor pulmonale, or bothdespite oxygen therapy; and FEV

M _ !"L &5*9)3(*9 ,)(-

*)(-*5 A\?@

_ !"L &5*9)3(*9 .5 -./.2*%.>+ 9)+(5);>().% .B*/&-6+*/'QVZ O&E:F8>58 !).

(213>86139 )683 &80>867;< ?@8A )+ ' 3./&:*D 9)+*'+*(-'( 5*C>)5*+ (-* )%&>( .B />:()&:* 3'5* &5.4)9*5+ ,-.%**9 (. ,.50 (.2*(-*5 3:.+*:67 $% &5)%3)&:*1 >+* .B ' B.5/':+(5>3(>5*9 &5.25'/ (-'( 9*(*5/)%*+ -., *'3- 3./&.%*%(is delivered should make care more efcient and effective,;>( (-* *4)9*%3* B.5 (-)+ )+ 9)4)9*97 = /*('<'%':6+)+ .B +/'::(5)':+ 3.%3:>9*9 (-'( '% )%(*25'(*9 3'5* &5.25'/ )/&5.4*9' %>/;*5 .B 3:)%)3': .>(3./*+1 ':(-.>2- %.( /.5(':)(6P""7$% 3.%(5'+(1 ' :'52* />:()<3*%(*5 +(>96 ,)(-)% '% *D)+()%2well-organized system of care did not conrm thisP"M7 E-*pragmatic conclusion is that well organized care is important,;>( (-*5* /'6 ;* %. '94'%('2* )% +(5>3(>5)%2 )( ()2-(:6 )%(. 'formalized program.

?:553/107E< W>::*3(./6 )+ '% .:9*5 +>52)3': &5.3*9>5* B.5;>::.>+ */&-6+*/'7 U*/.4': .B ' :'52* ;>::' (-'( 9.*+ %.(3.%(5);>(* (. 2'+ *D3-'%2* 9*3./&5*++*+ (-* '9R'3*%( :>%2&'5*%3-6/'7 8>:/.%'56 -6&*5(*%+).%1 -6&*53'&%)'1 '%9+*4*5* */&-6+*/' '5* %.( ';+.:>(* 3.%(5')%9)3'().%+ B.5;>::*3(./67

$2AA:27:E8 !238U &>FW6<WA:<8 !238U 2>F "6;9:58 !238B

E-* 9)+*'+* (5'R*3(.56 )% ?@8A )+ >+>'::6 /'50*9 ;6 '25'9>': 9*3:)%* )% -*':(- +('(>+ '%9 )%35*'+)%2 +6/&(./+1&>%3(>'(*9 ;6 '3>(* *D'3*5;'().%+ (-'( '5* '++.3)'(*9,)(- '% )%35*'+*9 5)+0 .B 96)%2KQ"7 =:(-.>2- /.5(':)(6following hospitalization for an acute exacerbation of?@8A )+ B'::)%2KQM1 )( +():: 4'5)*+ ;*(,**% !QLKQ! '%9Z"LKQQ7 85.25*++)4* 5*+&)5'(.56 B'):>5*1 3'59).4'+3>:'59)+*'+*+1 /':)2%'%3)*+ '%9 .(-*5 9)+*'+*+ '5* (-* &5)/'56cause of death in patients with COPD hospitalized for an*D'3*5;'().%KQQ. For all these reasons, palliative care, end-.B<:)B* 3'5*1 '%9 -.+&)3* 3'5* '5* )/&.5('%( 3./&.%*%(+ .B(-* 3'5* .B &'()*%(+ ,)(- '94'%3*9 ?@8A7

8'::)'()4* 3'5* )+ (-* ;5.'9*+( (*5/ '%9 )%3.5&.5'(*+ O;>(is not limited to) both end-of-life care (care for those whoare actively dying) as well as hospice care (a model for9*:)4*56 .B *%9<.B<:)B* 3'5* B.5 &'()*%(+ ,-. '5* (*5/)%'::6ill and predicted to have less than months to live). The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focus on the goals of enhancing quality of life, optimizingB>%3().%1 -*:&)%2 ,)(- 9*3)+).% /'0)%2 ';.>( *%9<.B<:)B* 3'5*1&5.4)9)%2 */.().%': '%9 +&)5)(>': +>&&.5( (. &'()*%(+ '%9 (-*)B'/):)*+KQT7 $%35*'+)%2:61 &'::)'()4* 3'5* (*'/+ '5* '4'):';:*for consultation for hospitalized patients and such teams are

5'&)9:6 )%35*'+)%2 )% %>/;*5+ '%9 3'&'3)(6KQV7 =4'):';):)(6 B.5.>(&'()*%( &'::)'()4* 3'5* 3.%+>:('().% )+ :*++ 3.//.%1 ;>(-'+ ;**% +-.,% (. )/&5.4* C>':)(6 .B :)B*1 5*9>3* +6/&(./+'%9 *4*% &5.:.%2 +>54)4': B.5 +./* &'()*%(+1 +>3- '+ (-.+*,)(- '94'%3*9 :>%2 3'%3*5 KQP7 ?:)%)3)'%+ 3'5)%2 B.5 &'()*%(+with COPD should help identify patients who could benetB5./ &'::)'()4* 3'5* +*54)3*+ '%9 )9*%()B6 '4'):';:* &'::)'()4*3'5* 5*+.>53*+ ,)(-)% (-*)5 3.//>%)(6 B.5 (-*+* &'()*%(+7

For patients with the most advanced and terminal illness,hospice services may provide additional benet. Hospice+*54)3*+ .B(*% B.3>+ .% &'()*%(+ ,)(- +*4*5* 9)+';):)(6 .5+6/&(./ ;>59*% '%9 /'6 &5.4)9* (-*+* +*54)3*+ ,)(-)% (-*

&'()*%(G+ -./* .5 )% -.+&)3* ;*9+ )% 9*9)3'(*9 -.+&)3* >%)(+.5 .(-*5 )%+()(>().%+ +>3- '+ -.+&)(':+ .5 %>5+)%2 -./*+7The National Hospice and Palliative Care Organization(http://www.nhpco.org) provides guidance for selecting&'()*%(+ ,)(- %.%<3'%3*5 9)+*'+*+ :)0* ?@8A B.5 '33*++(. -.+&)3* +*54)3*+ OB.5 *D'/&:*1 9)+';:)%2 96+&%*' '( 5*+((-'( )+ &..5:6 5*+&.%+)4* (. ;5.%3-.9):'(.5+ '%9 &5.25*++).%.B '94'%3*9 9)+*'+* 9*/.%+(5'(*9 ;6 )%35*'+)%2hospitalizations or emergency department visits)KQK1KQP7 E-*+*guidelines discuss the difculties in accurately predicting theprognosis of patients with advanced COPD, but recognize(-* '&&5.&5)'(*%*++ .B &5.4)9)%2 -.+&)3* +*54)3*+ B.5 +./*.B (-*+* &'()*%(+KQT7

8/16/2019 GOLD Report 2016


!"#$%&'

(

!"#"$%!%#& ()

*&"+,% -(./

8/16/2019 GOLD Report 2016


!" !"#"$%!%#& () *&"+,% -(./

)&* $,-.%/0

• Identication and reduction of exposure to risk factorsare important steps in the prevention and treatmentof COPD. All individuals who smoke should beencouraged to quit.

• The level of FEV$ is an inadequate descriptor of the

impact of the disease on patients and for this reasonindividualized assessment of symptoms and futurerisk of exacerbation should also be incorporated intothe management strategy for stable COPD.

• Pharmacologic therapy is used to reduce symptoms,reduce frequency and severity of exacerbations,and improve health status and exercise tolerance.

Existing medications for COPD have not beenconclusively shown to modify the long-term decline inlung function that is the hallmark of this disease.

• For both beta"-agonists and anticholinergics, long-

acting formulations are preferred over short-actingformulations. Based on efcacy and side effects,inhaled bronchodilators are preferred over oralbronchodilators.

• Long-term treatment with inhaled corticosteroidsadded to long-acting bronchodilators isrecommended for patients at high risk ofexacerbations.

• Long-term monotherapy with oral or inhaledcorticosteroids is not recommended in COPD.

• The phosphodiesterase-4 inhibitor roumilast may beuseful to reduce exacerbations for patients with FEV

$

< 50% predicted, chronic bronchitis, and frequentexacerbations.

• Inuenza vaccines can reduce the risk of seriousillness (such as hospitalization due to lowerrespiratory tract infections) and death in COPDpatients.

• Currently, the use of antibiotics is not indicatedin COPD, other than for treating infectiousexacerbations of COPD and other bacterialinfections.

• All COPD patients with breathlessness when walking

at their own pace on level ground appear to benetfrom rehabilitation and maintenance of physicalactivity, improving their exercise tolerance and qualityof life, and reducing symptoms of dyspnea andfatigue.

Once COPD has been diagnosed, effective management

should be based on an individualized assessment of disease

in order to reduce both current symptoms and future risks

(%1234 (56). These goals should be reached with minimal

side effects from treatment, a particular challenge in COPD

patients because they commonly have comorbidities that

also need to be carefully identied and treated.

It is crucial for patients with COPD to understand the nature

of their disease, the risk factors for its progression, andtheir role and that of their health care workers in achieving

optimal management and health outcomes. The type of

health care workers seen, and the frequency of visits, will

depend on the health care system. Ongoing monitoring

should ensure that the goals of treatment are being met and

should include continuous evaluation of exposure to risk

factors and monitoring of disease progression, the effect of

treatment and possible adverse effects, exacerbation history,

and comorbidities. In addition, patients should receive

general advice on healthy living, including diet and the fact

that physical exercise is safe and encouraged for people with

COPD.

Identication and reduction of exposure to risk factors are

important in the treatment and prevention of COPD. Since

cigarette smoking is the most commonly encountered and

easily identiable risk factor, smoking cessation should be

encouraged for all individuals who smoke. Reduction of total

personal exposure to occupational dusts, fumes, and gases

and to indoor and outdoor air pollutants may be more difcult

but should be attempted.

!"#$%&' (0 7#.#8&7&.% ,9 /%#:;& !,$<

-.%',<=!%-,.

%1234 (565 8>13? @>A %A41BC4DB >@ /B1234 !,$<

• !"#$"%" '()*+,)'

• -)*.,%" "/".0$'" +,#".120"

• -)*.,%" 3"1#+3 '+1+4'

!"#

• 5."%"2+ 6$'"1'" *.,7."''$,2

• 5."%"2+ 126 +."1+ "/10".81+$,2'

• !"640" ),.+1#$+(

8/16/2019 GOLD Report 2016


!"#"$%!%#& () *&"+,% -(./ !!

%>21EE> /C>F4

Smoking cessation is the key intervention for all COPD

patients who continue to smoke (&GHI4DE4 #). Health careproviders are important to the delivery of smoking cessationmessages and interventions and should encourage allpatients who smoke to quit, even when patients visit a healthcare provider for reasons unrelated to COPD or breathingproblems.

,EEJK1BH>D13 &LK>?JA4?

Although studies as yet have not been done to demonstratewhether interventions to reduce occupational exposuresalso reduce the burden of COPD, it seems common senseto advise patients to avoid continued exposures to potential

aggravants, if possible (&GHI4DE4 <).

-DI>>A 1DI ,JBI>>A #HA $>33JBH>D

Reducing the risk from indoor and outdoor air pollution isfeasible and requires a combination of public policy, localand national resources, cultural changes, and protectivesteps taken by individual patients. Reduction of exposureto smoke from biomass fuel, particularly among womenand children, is a crucial goal to reduce the prevalence ofCOPD worldwide. Efcient ventilation, non-polluting cookingstoves, use of ues, and similar interventions are feasibleand should be recommended37,30 (&GHI4DE4 :).

In previous versions of the GOLD report, COPD treatmentrecommendations were based on spirometry only. This is inkeeping with the fact that most of the clinical trial evidenceabout treatment efcacy in COPD is oriented around baseline

FEV$. However, FEV$ alone is a poor descriptor of diseasestatus and for this reason the treatment strategy for stableCOPD should also consider an individual patient’s symptomsand future risk of exacerbations. This individualizedassessment is summarized in %1234 (5M.

7>GHDN @A>C !3HDHE13 %AH13? B> '4E>CC4DI1BH>D? @>A'>JBHD4 $A1EBHE4 O !>D?HI4A1BH>D?

The guidance for clinical practice presented below isbased on evidence from clinical trials, as detailed in thediscussion of Evidence Levels at the beginning of thisdocument. However, it is important to recognize that allclinical trials recruit restricted groups of patients; this limits

their generalizability. In COPD the key inclusion criteria are:baseline FEV

$, acute bronchodilator reversibility, smoking

history, symptoms and a prior history of exacerbations. A fewgeneral considerations related to these inclusion criteria arediscussed below.

+0123452 )%6 78 The evidence for pharmacological treatment

of COPD is mostly based on the severity of airow limitation(FEV

$% predicted), and GOLD spirometry classication

has often been used as an entry criterion for clinical trials.There is almost no evidence on efcacy of COPD treatmentsin patients with FEV

$ 70% predicted (GOLD 1), and no

evidence at all concerning anti-inammatory treatment

in patients with FEV$ 0% predicted. Many studies ofcombination medications (inhaled corticosteroids pluslong-acting beta

"-agonists) have been limited to GOLD 3-4

(Severe-Very Severe airow limitation) patients. As no trialshave been carried out purely in GOLD 2 patients, evidenceof the efcacy of combination treatment in this group hasto be drawn from studies that included such patients as asubset of participants. Large studies such as TORCH$%& andUPLIFT214 each contained over 2,000 GOLD 2 patients, albeiin the lower stratum of GOLD 2 (FEV

$ < 0% predicted). In

general, it is important to draw a distinction between absenceof evidence that a treatment works and presence of evidencethat a treatment does not work.

"9:;2 +<=59>=?430;=< @2A2<14B434;C8 Many COPD trialshave used low reversibility of airow limitation as an entrycriterion. Acute reversibility is not a reliable measurement31

and, in general, acute reversibility in response tobronchodilator is a poor predictor of a treatment’s benet forFEV

$ after one year 32. Thus, this common clinical trial entry

criterion has limited impact on the reliability of therapeuticrecommendations.

%'&#%7&.% ,9 /%#:;& !,$<-<&.%-9* #.< '&<=!& &P$,/='&

%, '-/) 9#!%,'/

%1234 (5M5 7>I43 >@ /QCKB>CR'H?F >@ &G13J1BH>D >@ !,$<

Patient

Category

Characteristics Spirometric

Classification

Exacerbations

per year

C AT m MRC

! #$% &'()* #+(( ,-./0$.( 12#3 456 ≤1 7 48 854

9 #$% &'()* :$;+ ,-./0$.( 12#3 456 ≤1 ≥ 10 ≥ 2

< ='>? &'()* #+(( ,-./0$.( 12#3 @5A B 6 7 48 854

3 ='>? &'()* :$;+ ,-./0$.( 12#3 @5A B 6 ≥ 10 ≥ 2

(C) (D)

(A) (B)

R i s k

( E x a c r b a t i o n

H i s t o r y )

R i s k

( G o l d

C l a s s i fi c a t i o n

o f A i r fl o w L

i m i t a t i o n )

Symptoms

Breathlessness

CAT < 10 CAT ≥ 10

mMRC 0-1 mMRC ≥ 2

≥ 2

or

≥1 leading

to hospital

admission

1 (not leading

to hospital

admission)

0

!"#$ &''#''($) *('+, -"..'# /"# "()"#'/ *('+ &--.*0($) /. 1234 )*&0# .* #5&-#*6&/(.$ "('/.*78

92$# .* :.*# ".';(/&<(=&/(.$' >.* ?2@4 #5&-#*6&/(.$' '".A<0 6# -.$'(0#*#0 "()" *('+8B

8/16/2019 GOLD Report 2016


34 !"#"$%!%#& () *&"+,% -(./

*CDE;=D18 Almost all studies have included patients with

respiratory symptoms; there are no data on asymptomatic

patients. No studies have reported results based upon

stratied symptom levels.

%F092<B0;4=5 .<2A25;4=58 Studies in which exacerbations

are a major outcome often enrich the patient populationby requiring a history of frequent exacerbations in the

preceding year, as it is often easier to demonstrate an effect

of treatment preventing exacerbations if the exacerbations

actually occur. However, large trials that have not used this

entry criterion have also shown reductions in exacerbations,

even in patients with less severe airow limitation15,214. The

patient’s own history of exacerbations appears to be the

most powerful predictor of future exacerbations$!", so the

GOLD panel assumed that it is safe to extrapolate evidence

of efcacy from clinical trials to appropriate patients in routine

practice, regardless of the trial’s entry criteria concerning

previous exacerbation history.

*:BG$<=:E "503C1418 Results of clinical trials potentially

apply to every member of the intention-to-treat population,

whether they lie in the center of the distribution of severity or

at the extremes. Sub-group analysis, whether pre-specied

or not, must be used with caution. For example, if a treatment

has no effect in the intention-to-treat population, but appears

to have an effect that is conned to one sub-group, there is a

strong likelihood that one of the other groups would be worse

on the treatment. In contrast, subgroup analysis is useful

if it shows that a treatment effect is consistent in size and

direction across the range of patients recruited to the study.

In summary, sub-group analysis does not provide robust

evidence that a treatment works in a specic subgroup, butit can provide condence that the results from the intention-

to-treat population apply to patients who met the study entry

criteria. Subgroup analysis can also generate hypotheses to

be tested in subsequent trials.

Non-pharmacologic management of COPD according to the

individualized assessment of symptoms and exacerbation

risk is shown in %1234 (5S.

/C>FHDN !4??1BH>D

Smoking cessation should be considered the most important

intervention for all COPD patients who smoke regardless of

the level of disease severity.

$TQ?HE13 #EBHGHBQ

Physical activity is recommended for all patients with COPD.

There is very little COPD-specic evidence to support

recommendations for physical activity other than studies of

pulmonary rehabilitation (the physical exercise component

is believed to provide the most benet). However, given the

overall population benets of physical exercise and its role inprimary and secondary prevention of cardiovascular disease,

it seems intuitively correct to recommend daily physical

activity.

'4T12H3HB1BH>D

Although more information is needed on criteria for

patient selection for pulmonary rehabilitation programs, all

COPD patients appear to benet from rehabilitation and

maintenance of physical activity, improving their exercise

tolerance and experiencing decreased dyspnea and

fatigue33 (&GHI4DE4 #). Several studies have documented

an effect of pulmonary rehabilitation in patients with

breathlessness, usually mMRC 1, and following acute

exacerbations. Data suggest that these benets can be

sustained even after a single pulmonary rehabilitation

program341,34,35. Benet does wane after a rehabilitation

program ends, but if exercise training is maintained at home

the patient’s health status remains above pre-rehabilitation

levels (&GHI4DE4 :).

U1EEHD1BH>D

Decisions about vaccination in COPD patients depend on

local policies, availability, and affordability.

.,.V$"#'7#!,;,8-! %'&#%7&.%

%1234 (5S5 .>DV$T1AC1E>3>NHE 71D1N4C4DB >@ !,$<

$!%&'"% )*+,- .//'"%&!0 1'2+33'"#'# 4'-'"#&"5 +" 6+2!0 ),&#'0&"'/

9 :),;$27 0"''1+$,2 <012 $20#46" *31.)10,#,7$0 +."1+)"2+= 53('$01# 10+$%$+( >#4 %100$21+$,2

52"4),0,001# %100$21+$,2

?@A :),;$27 0"''1+$,2 <012 $20#46" *31.)10,#,7$0 +."1+)"2+= 53('$01# 10+$%$+( >#4 %100$21+$,2

54#),21.( ."318$#$+1+$,2 52"4),0,001# %100$21+$,2

8/16/2019 GOLD Report 2016


!"#"$%!%#& () *&"+,% -(./ !&

Pharmacologic therapy in COPD is used to reduce

symptoms, reduce the frequency and severity of

exacerbations, and improve health status and exercise

tolerance. Existing medications for COPD have not been

conclusively shown to modify the long-term decline in lungfunction that is the hallmark of this disease12,15,175,17.

The classes of medications commonly used in treating

COPD are shown in %1234 S5S and a detailed description

of the effects of these medications is given in Chapter 3.

The choice within each class depends on the availability of

medication and the patient’s response. A proposed model for

initial pharmacological management of COPD according to

the individualized assessment of symptoms and exacerbation

risk is shown in %1234 (5(.

$<=:E " E0;425;1 have few symptoms and a low risk of

exacerbations. Specic evidence for the effectiveness ofpharmacologic treatments is not available for patients with

FEV$ 0% predicted (GOLD 1). However, for all Group

A patients, a short-acting bronchodilator used as needed

is recommended as rst choice based on its effect on lung

function and breathlessness&'&. An alternative choice

is a combination of short-acting bronchodilators or the

introduction of a long-acting bronchodilator. The evidence

for this step-up is weak; few studies of the combination

exist11,3, and most trials of therapy with long-acting

bronchodilators have been performed in patients with more

severe airow limitation212,37.

$<=:E + E0;425;1 have more signicant symptoms but still

a low risk of exacerbations. Long-acting bronchodilators are

superior to short-acting bronchodilators (taken as needed,

or prn) and are therefore recommended212,37. There

is no evidence to recommend one class of long-acting

bronchodilators over another for initial treatment. In the

individual patient, the choice should depend on the patient’s

perception of symptom relief. For patients with severe

breathlessness, the alternative choice is a combination of

long-acting bronchodilators237,23. Other possible treatments

include short-acting bronchodilators and theophylline, the

latter of which can be used if inhaled bronchodilators are

unavailable or unaffordable.

$<=:E - E0;425;1 have few symptoms but a high risk

of exacerbations. As rst choice a xed combination of

inhaled corticosteroid/long-acting beta"-agonist or a long-

acting anticholinergic is recommended15,212,214,240,244,251,3 .Unfortunately, there is only one study directly comparingthese treatments, which makes differentiation difcult3.

As an alternative choice a combination of two long-actingbronchodilators or the combination of inhaled corticosteroid/

long-acting anticholinergic can be used. Both long-actinganticholinergic and long-acting beta

"-agonist reduce the

risk of exacerbations212,37, and although good long-termstudies are lacking, this principle of combination treatmentseems sound (although in many countries expensive).The recommendation for a combination of inhaledcorticosteroid/long-acting anticholinergic is not evidence-based, but this lack of evidence seems to be the result oflack of interest from the pharmaceutical industry ratherthan doubts about the rationale. A phosphodiesterase-4inhibitor used in combination with at least one long-actingbronchodilator could be considered if the patient has chronicbronchitis24,2. Other possible treatments include short-acting bronchodilators and theophylline if long-acting inhaledbronchodilators are unavailable or unaffordable.

$<=:E / E0;425;1 have many symptoms and a high riskof exacerbations. The rst choice of therapy is inhaledcorticosteroid plus long-acting beta

"-agonist or long-acting

anticholinergic, although there are conicting ndings

concerning this treatment"&(; support for it mainly comesfrom short-term studies257,53,53 (&GHI4DE4 :). As secondchoice a combination of all three classes of drugs (inhaledcorticosteroids/long-acting beta

"-agonist/long-acting

anticholinergic) is recommended"&'. It is also possible to adda phosphodiesterase-4 inhibitor to the treatment chosen asrst choice, provided the patient has chronic bronchitis"''.

A phosphodiesterase-4 inhibitor is effective when addedto a long-acting bronchodilator 24, whereas evidence of itsbenet when added to inhaled corticosteroid comes fromless valid secondary analyses. Other possible treatmentsinclude short-acting bronchodilators, and theophyllineor carbocysteine"%' can be used if long-acting inhaled

bronchodilators are unavailable or unaffordable.

:A>DET>IH31B>A? O '4E>CC4DI1BH>D?

• For both beta"-agonists and anticholinergics, long-acting

formulations are preferred over short-acting formulations(&GHI4DE4 #).

• The combined use of short- or long-acting beta"-agonists

and anticholinergics may be considered if symptoms arenot improved with single agents')" (&GHI4DE4 :).

• Based on efcacy and side effects inhaledbronchodilators are preferred over oral bronchodilators(&GHI4DE4 #).

• Based on evidence of relatively low efcacy andmore side effects, treatment with theophylline is notrecommended unless other long-term treatmentbronchodilators are unavailable or unaffordable

(&GHI4DE4 :).

$"#'7#!,;,8-! %'&#%7&.%

8/16/2019 GOLD Report 2016


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• There is no evidence to recommend a short-term

therapeutic trial with oral corticosteroids in patients with

COPD to identify those who will respond to inhaled

corticosteroids or other medications.• Long-term treatment with inhaled corticosteroids

is recommended for patients with severe and very

severe COPD and frequent exacerbations that are not

adequately controlled by long-acting bronchodilators

(&GHI4DE4 #).

• Long-term monotherapy with oral corticosteroids is not

recommended in COPD (&GHI4DE4 #).

• Long-term monotherapy with inhaled corticosteroids is

not recommended in COPD because it is less effective

than the combination of inhaled corticosteroids with long-

acting beta"-agonists (&GHI4DE4 #).

• Long-term treatment containing inhaled corticosteroids

should not be prescribed outside their indications, due tothe risk of pneumonia and the possibility of an increased

risk of fractures following long-term exposure540.

• The phosphodiesterase-4 inhibitor, roumilast, may also

be used to reduce exacerbations for patients with chronic

bronchitis, severe and very severe COPD, and frequent

exacerbations that are not adequately controlled by long-

acting bronchodilators (&GHI4DE4 :).

Routine follow-up is essential in COPD. Lung function

can be expected to worsen over time, even with the bestavailable care. Symptoms and objective measures of airowlimitation should be monitored to determine when to modifytherapy and to identify any complications that may develop.

As at the initial assessment, follow-up visits should include adiscussion of symptoms, particularly any new or worseningsymptoms, and a physical examination. Comprehensiveself-management or routine monitoring does not appearto show long term benets in terms of quality of life or selfefcacy over usual care alone in COPD patients in generalpractice&''.

7>DHB>A <H?41?4 $A>NA4??H>D 1DI <4G43>KC4DB >@

!>CK3HE1BH>D?

!201:<2D25;18 Decline in lung function is best tracked byspirometry performed at least once a year to identify patientswhose lung function is declining quickly. Questionnairessuch as the COPD Assessment Test 2-"&3124 can beperformed every two to three months; trends and changesare more valuable than single measurements.

*CDE;=D18 At each visit, inquire about changes insymptoms since the last visit, including cough and sputum,

breathlessness, fatigue, activity limitation, and sleepdisturbances.

*D=H45I *;0;:18 At each visit, determine current smokingstatus and smoke exposure; strongly encourage participationin programs to reduce and eliminate wherever possibleexposure to COPD risk factors.

7>DHB>A $T1AC1E>BT4A1KQ 1DI ,BT4A 74IHE13 %A41BC4DB

*n order to adjust therapy appropriately as the diseaseprogresses, each follow-up visit should include a discussionof the current therapeutic regimen. Dosages of variousmedications, adherence to the regimen, inhaler technique,effectiveness of the current regime at controlling symptoms,and side effects of treatment should be monitored.Treatment modications should be recommendedas appropriate with a focus on avoiding unnecessarypolypharmacy.

At the individual patient level, measurements such as FEV$

and questionnaires such as the CAT are useful but are notcompletely reliable, because the size of a clinically importantresponse is smaller than between-assessment variability. Forthis reason, the following questions might be useful whendeciding whether a patient has had a symptomatic responseto treatment:

• Have you noticed a difference since starting this

treatment

• If you are better:

Are you less breathless

Can you do more

Can you sleep better

Describe what difference it has made to you.• Is that change worthwhile to you

7>DHB>A &L1E4A21BH>D "H?B>AQ

Evaluate the frequency, severity, and likely causes ofany exacerbations!%$. Increased sputum volume, acutelyworsening dyspnea, and the presence of purulent sputumshould be noted. Specic inquiry into unscheduled visitsto providers, telephone calls for assistance, and use ofurgent or emergency care facilities is important. Severityof exacerbations can be estimated by the increased needfor bronchodilator medication or corticosteroids and by theneed for antibiotic treatment. Hospitalizations should be

documented, including the facility, duration of stay, and anyuse of critical care or mechanical ventilatory support.

7>DHB>A !>C>A2HIHBH4?

Comorbidities are common in COPD, amplify the disability

associated with COPD, and can potentially complicate

its management. Until more integrated guidance about

disease management for specic comorbid problems

7,.-%,'-.8 #.< 9,;;,XV=$

8/16/2019 GOLD Report 2016


3 !"#"$%!%#& () *&"+,% -(./

becomes available, the focus should be on identication and

management of these individual problems in line with local

treatment guidance (See also Chapter ).

/JAN4AQ HD BT4 !,$< $1BH4DB

Postoperative pulmonary complications are as importantand common as postoperative cardiac complications

and, consequently, are a key component of the increased

risk posed by surgery in COPD patients!%". The principal

potential factors contributing to the risk include smoking,

poor general health status, age, obesity, and COPD severity.

A comprehensive denition of postoperative pulmonary

complications should include only major pulmonary

respiratory complications, namely lung infections, atelectasis

and/or increased airow limitation, which all potentially result

in acute respiratory failure and aggravation of underlying

COPD21,33-35.

Increased risk of postoperative pulmonary complicationsin COPD patients may vary with the severity of COPD,

although the surgical site is the most important predictor; risk

increases as the incision approaches the diaphragm34. Most

reports conclude that epidural or spinal anesthesia have a

lower risk than general anesthesia, although the results are

not totally uniform.

For lung resection, the individual patient’s risk factors should

be identied by careful history, physical examination, chest

radiography, and pulmonary function tests. Although the

value of pulmonary function tests remains contentious, there

is consensus that all COPD candidates for lung resection

should undergo a complete battery of tests, includingspirometry with bronchodilator response, static lung volumes,

diffusing capacity, and arterial blood gases at rest3,37.

COPD patients at high risk for surgical complications due

to poor lung function should undergo further lung function

assessment, for example, tests of regional distribution of

perfusion and exercise capacity3,37.

The risk of postoperative complications from lung resection

appears to be increased in patients with decreased predicted

postoperative pulmonary function (FEV$ or DL

CO < 30-40%

predicted) or exercise capacity (peak VO" < 10 ml/kg/min or

35% predicted). The nal decision to pursue surgery should

be made after discussion with the surgeon, pulmonary

specialist, primary clinician, and the patient. To prevent

postoperative pulmonary complications, stable COPD

patients clinically symptomatic and/or with limited exercise

capacity should be treated intensively before surgery, with

all the measures already well established for stable COPD

patients who are not about to have surgery. Surgery should

be postponed if an exacerbation is present.

8/16/2019 GOLD Report 2016


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department the rst actions are to provide supplemental

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exacerbation is poor, with a ve-year mortality rate of

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'-=-)*,6,+,(/ @(:?:A '&)6,-8&/'>9&) 6,/(&/( -) 9>.? '&.'()CA

5)(8,->/ &6=,//,-./ 0-) 1234 (%&'()*&+,-./A '9,.,'&9

/(8(),+7 -0 +<( ,.6(% (%&'()*&+,-. &.6 .((6 0-) 9-.?D+()=

-%7?(. +<()&57 &+ 6,/'<&)?(Z"YAZ"Z: 3&+,(.+/ '<&)&'+(),E(6 *7

& <,?<() 5)(8&9(.'( &.6 /(8(),+7 -0 )(/5,)&+-)7 /7=5+-=/A

#//&//3&.%

%789: (<=< #;;:;;A:B@ GH !,$1 &I7J:?87@CGB;0 3:KCJ79 "C;@G?L

• Severity of COPD based on degree of airow limitation• Duration of worsening or new symptoms• umber of previous episodes (total/hospitalizations)• Comorbidities• Present treatment regimen• Previous use of mechanical ventilation

%789: (<>< #;;:;;A:B@ GH !,$1 &I7J:?87@CGB;0 /CDB; GH /:M:?C@L

• Use of accessory respiratory muscles• Paradoxical chest wall movements• orsening or new onset central cyanosis• Development of peripheral edema• Hemodynamic instability• Deteriorated mental status

%'&#%3&.% ,$%-,./

%789: (<E< $G@:B@C79 -BKCJ7@CGB; HG?

"G;NC@79 #;;:;;A:B@ G? #KAC;;CGBO

• Marked increase in intensity of symptoms, such as suddendevelopment of resting dyspnea

• Severe underlying COPD• Onset of new physical signs (e.g., cyanosis, peripheral edema)• Failure of an exacerbation to respond to initial medical management• Presence of serious comorbidities (e.g., heart failure or newly

occurring arrhythmias)• Frequent exacerbations• Older age• Insufcient home support

!"#$%& ()*#+($)* ,))- .# /) $#,*0-)()-1

8/16/2019 GOLD Report 2016


!H !"#"$%!%#& () %*"+%,-"&.(#/

5--)() F>&9,+7 -0 9,0(A I-)/( 9>.? 0>.'+,-.A 9-I() (%()',/(

'&5&',+7A 9-I() 9>.? 6(./,+7 &.6 +<,'M(.(6 *)-.'<,&9 I&99/

-. 1;D/'&. &)( &9/- &+ ,.')(&/(6 ),/M -0 /<-)+() 9-.?D+()=

/>)8,8&9 0-99-I,.? &. &'>+( 1234 (%&'()*&+,-.Z"\:

$P7?A7JG9GDCJ %?:7@A:B@

d-.?D+()= 5)-?.-/,/ 0-99-I,.? <-/5,+&9,E&+,-. 0-) 1234

exacerbation is poor, with a ve-year mortality rate of

&*->+ Y"WZ"!: J&'+-)/ ,.6(5(.6(.+97 &//-',&+(6 I,+<

5--) ->+'-=( ,.'9>6( -96() &?(A 9-I() *-67 =&// ,.6(%A

'-=-)*,6,+,(/ @(:?:A '&)6,-8&/'>9&) 6,/(&/( -) 9>.? '&.'()CA

5)(8,->/ &6=,//,-./ 0-) 1234 (%&'()*&+,-./A '9,.,'&9

/(8(),+7 -0 +<( ,.6(% (%&'()*&+,-. &.6 .((6 0-) 9-.?D+()=

-%7?(. +<()&57 &+ 6,/'<&)?(Z"YAZ"Z: 3&+,(.+/ '<&)&'+(),E(6 *7

& <,?<() 5)(8&9(.'( &.6 /(8(),+7 -0 )(/5,)&+-)7 /7=5+-=/A

5--)() F>&9,+7 -0 9,0(A I-)/( 9>.? 0>.'+,-.A 9-I() (%()',/(

'&5&',+7A 9-I() 9>.? 6(./,+7 &.6 +<,'M(.(6 *)-.'<,&9 I&99/

-. 1;D/'&. &)( &9/- &+ ,.')(&/(6 ),/M -0 /<-)+() 9-.?D+()=

/>)8,8&9 0-99-I,.? &. &'>+( 1234 (%&'()*&+,-.Z"\:

;<( +<)(( '9&//(/ -0 =(6,'&+,-./ =-/+ '-==-.97

>/(6 0-) (%&'()*&+,-./ -0 1234 &)( *)-.'<-6,9&+-)/A

'-)+,'-/+()-,6/A &.6 &.+,*,-+,'/:

/01234563789 -218601:7;5312<= U9+<->?< +<()( &)( .-

'-.+)-99(6 +),&9/A /<-)+D&'+,.? ,.<&9(6 *(+&HD&?-.,/+/ I,+< -)

I,+<->+ /<-)+D&'+,.? &.+,'<-9,.()?,'/ &)( >/>&997 +<( 5)(0())(6*)-.'<-6,9&+-)/ 0-) +)(&+=(.+ -0 &. (%&'()*&+,-.HR"AHRL

@&MCK:BJ: !C: ;<()( &)( .- '9,.,'&9 /+>6,(/ +<&+ <&8(

(8&9>&+(6 +<( >/( -0 ,.<&9(6 9-.?D&'+,.? *)-.'<-6,9&+-)/

@(,+<() *(+&HD&?-.,/+/ -) &.+,'<-9,.()?,'/C I,+< -) I,+<->+

,.<&9(6 '-)+,'-/+()-,6/ 6>),.? &. (%&'()*&+,-.: U /7/+(=&+,'

)(8,(I -0 +<( )->+( -0 6(9,8()7 -0 /<-)+D&'+,.? *)-.'<-6,9&+-)/

found no signicant differences in FEVL *(+I((. =(+()(6D

6-/( ,.<&9()/ @I,+< -) I,+<->+ & /5&'() 6(8,'(C &.6

.(*>9,E()/!H"A &9+<->?< +<( 9&++() '&. *( =-)( '-.8(.,(.+ 0-)

/,'M() 5&+,(.+/: V.+)&8(.->/ =(+<79%&.+<,.(/ @+<(-5<799,.(

-) &=,.-5<799,.(C &)( '-./,6()(6 /('-.6D9,.( +<()&57A -.97

to be used in selected cases when there is insufcient

)(/5-./( +- /<-)+D&'+,.? *)-.'<-6,9&+-)/!HLD!HY

@&MCK:BJ:6). Side effects of methylxanthines are signicant and

their benecial effects in terms of lung function and clinical

(.65-,.+/ &)( =-6(/+ &.6 ,.'-./,/+(.+!HZA!H\:

+123761<3>217:<= 4&+& 0)-= /+>6,(/ ,. /('-.6&)7 <(&9+<'&)( ,.6,'&+( +<&+ /7/+(=,' '-)+,'-/+()-,6/ ,. 1234(%&'()*&+,-./ /<-)+(. )('-8()7 +,=(A ,=5)-8( 9>.? 0>.'+,-.@J$K

LC &.6 &)+(),&9 <75-%(=,& @3&2

HC!HTD!QL @&MCK:BJ: #CA

&.6 )(6>'( +<( ),/M -0 (&)97 )(9&5/(A +)(&+=(.+ 0&,9>)(Y!LA &.69(.?+< -0 <-/5,+&9 /+&7!HTA!Q"A!QH: U 6-/( -0 !" =? 5)(6.,/-.(5() 6&7 0-) Y 6&7/ ,/ )('-==(.6(6YZ\AZH! @&MCK:BJ:6), although there are insufcient data to provide rm

'-.'9>/,-./ '-.'().,.? +<( -5+,=&9 6>)&+,-. -0 '-)+,'-/+()-,6+<()&57 -0 &'>+( (%&'()*&+,-./ -0 1234Y!H: ;<()&57 I,+<-)&9 5)(6.,/-9-.( ,/ 5)(0()&*9(!QQ: O(*>9,/(6 *>6(/-.,6(&9-.( =&7 *( &. &9+().&+,8( @&9+<->?< =-)( (%5(./,8(C +--)&9 '-)+,'-/+()-,6/ ,. +<( +)(&+=(.+ -0 (%&'()*&+,-./!HRA!Q!A!QY:O(*>9,/(6 =&?.(/,>= &/ &. &6_>8&.+ +- /&9*>+&=-9+)(&+=(.+ ,. +<( /(++,.? -0 &'>+( (%&'()*&+,-./ -0 1234 <&/.- (00('+ -. J$K

LYZT:

"837?71376<: U9+<->?< +<( ,.0('+,->/ &?(.+/ ,. 1234

(%&'()*&+,-./ '&. *( 8,)&9 -) *&'+(),&9H\QA!QZA +<( >/( -0

&.+,*,-+,'/ ,. (%&'()*&+,-./ )(=&,./ '-.+)-8()/,&9YZR:

;<( >.'()+&,.+,(/ -),?,.&+( 0)-= /+>6,(/ +<&+ 6,6 .-+

6,00()(.+,&+( *(+I((. *)-.'<,+,/ @&'>+( -) '<)-.,'C &.61234 (%&'()*&+,-./A /+>6,(/ I,+<->+ 59&'(*-D'-.+)-9A &.6B

-) /+>6,(/ I,+<->+ '<(/+ gD)&7/ ,. I<,'< ,+ I&/ >.'9(&)

,0 5&+,(.+/ <&6 /,?./ -0 5.(>=-.,&: ;<()( ,/ (8,6(.'(

/>55-)+,.? +<( >/( -0 &.+,*,-+,'/ ,. (%&'()*&+,-./ I<(.

5&+,(.+/ <&8( '9,.,'&9 /,?./ -0 & *&'+(),&9 ,.0('+,-.A (:?:A

,.')(&/( ,. /5>+>= 5>)>9(.'(LL!: U /7/+(=&+,' )(8,(I -0 +<(

8()7 0(I &8&,9&*9( 59&'(*-D'-.+)-99(6 /+>6,(/ <&/ /<-I.

+<&+ &.+,*,-+,'/ )(6>'( +<( ),/M -0 /<-)+D+()= =-)+&9,+7 *7

\\WA +)(&+=(.+ 0&,9>)( *7 YQW &.6 /5>+>= 5>)>9(.'( *7

%789: (<F< 37B7D:A:B@ GH /:M:?: 8Q@

.G@ RCH:S%P?:7@:BCBD &I7J:?87@CGB;O

Assess severity of symptoms, blood gases, chest radiograph Administer supplemental oxygen therapy and obtain serial arterial blood

gas measurement Bronchodilators

Increase doses and/or frequency of short-acting bronchodilators Combine short-acting beta

!-agonists and anticholinergics

Use spacers or air-driven nebulizers Add oral or intravenous corticosteroids Consider antibiotics (oral or occasionally intravenous) when signs of

bacterial infection Consider noninvasive mechanical ventilation At all times

Monitor uid balance and nutrition Consider subcutaneous heparin or low molecular weight heparin Identify and treat associated conditions (e.g., heart failure,arrhythmias) Closely monitor condition of the patient

%789: (<(< %P:?7N:Q@CJ !GANGB:B@; GH "G;NC@79 37B7D:A:B@

!"#$%!&'(!) #+$$(!'

Oxygen therapy Ventilatory support

oninvasive ventilation Invasive ventilation

$"#'3#!,R,4-! %'&#%3&.%

Bronchodilators Corticosteroids Antibiotics Adjunct therapies

!"#$%& ()*#+($)* ,))- .# /) $#,*0-)()-1

8/16/2019 GOLD Report 2016


!"#"$%!%#& () %*"+%,-"&.(#/ !Q

!!W: ;<,/ )(8,(I />55-)+/ &.+,*,-+,'/ 0-) -.97 =-6()&+(97

-) /(8()(97 ,99 5&+,(.+/ I,+< 1234 (%&'()*&+,-./ I,+<

,.')(&/(6 '->?< &.6 /5>+>= 5>)>9(.'(!Q\A!QT: V. ->+5&+,(.+/A

/5>+>= '>9+>)(/ &)( .-+ 0(&/,*9( &/ +<(7 +&M( +-- 9-.? @&+

9(&/+ H 6&7/C &.6 0)(F>(.+97 6- .-+ ?,8( )(9,&*9( )(/>9+/

0-) +('<.,'&9 )(&/-./A ,:(:A =-)( +<&. ! <->)/ (9&5/(

*(+I((. (%5('+-)&+,-. -0 /5>+>= &.6 &.&97/,/ ,. +<(microbiology lab. Procalcitonin III, a marker that is specic

0-) *&'+(),&9 ,.0('+,-./A =&7 *( -0 8&9>( ,. +<( 6(',/,-. +- >/(

&.+,*,-+,'/!QRA *>+ +<,/ +(/+ ,/ (%5(./,8( &.6 +<>/ .-+ I,6(97

(/+&*9,/<(6: U /+>67 ,. 1234 5&+,(.+/ I,+< (%&'()*&+,-./

)(F>,),.? =('<&.,'&9 8(.+,9&+,-. @,.8&/,8( -) .-.,.8&/,8(C

,.6,'&+(6 +<&+ .-+ ?,8,.? &.+,*,-+,'/ I&/ &//-',&+(6 I,+<

,.')(&/(6 =-)+&9,+7 &.6 & ?)(&+() ,.',6(.'( -0 /('-.6&)7

.-/-'-=,&9 5.(>=-.,&!!":

V. />==&)7A &.+,*,-+,'/ /<->96 *( ?,8(. +- 5&+,(.+/

I,+< (%&'()*&+,-./ -0 1234 I<- <&8( +<)(( '&)6,.&9

/7=5+-=/ h ,.')(&/( ,. 67/5.(&A /5>+>= 8-9>=(A &.6

/5>+>= 5>)>9(.'( @&MCK:BJ: 6Cb <&8( +I- -0 +<( '&)6,.&9/7=5+-=/A ,0 ,.')(&/(6 5>)>9(.'( -0 /5>+>= ,/ -.( -0

+<( +I- /7=5+-=/ @&MCK:BJ: !Cb -) )(F>,)( =('<&.,'&9

8(.+,9&+,-. @,.8&/,8( -) .-.,.8&/,8(C @&MCK:BJ: 6CH\QAQYL:

;<( )('-==(.6(6 9(.?+< -0 &.+,*,-+,' +<()&57 ,/ >/>&997

YDL" 6&7/ @&MCK:BJ: 1C:

;<( '<-,'( -0 +<( &.+,*,-+,' /<->96 *( *&/(6 -. +<( 9-'&9*&'+(),&9 )(/,/+&.'( 5&++().: f/>&997 ,.,+,&9 (=5,),'&9+)(&+=(.+ ,/ &. &=,.-5(.,',99,. I,+< -) I,+<->+ '9&8>9&.,'&',6A =&')-9,6(A -) +(+)&'7'9,.(: V. 5&+,(.+/ I,+< 0)(F>(.+exacerbations, severe airow limitation!L\A!!LA &.6B-)(%&'()*&+,-./ )(F>,),.? =('<&.,'&9 8(.+,9&+,-.!LHA '>9+>)(/

0)-= /5>+>= -) -+<() =&+(),&9/ 0)-= +<( 9>.? /<->96 *(5()0-)=(6A &/ ?)&=D.(?&+,8( *&'+(),& @(:?:A ;=1>B9H903==F1481=C -) )(/,/+&.+ 5&+<-?(./ +<&+ &)( .-+ /(./,+,8( +- +<(&*-8(D=(.+,-.(6 &.+,*,-+,'/ =&7 *( 5)(/(.+: ;<( )->+(-0 &6=,.,/+)&+,-. @-)&9 -) ,.+)&8(.->/C 6(5(.6/ -. +<(&*,9,+7 -0 +<( 5&+,(.+ +- (&+ &.6 +<( 5<&)=&'-M,.(+,'/ -0 +<(&.+,*,-+,'A &9+<->?< 5)(0()&*97 &.+,*,-+,'/ &)( ?,8(. -)&997:V=5)-8(=(.+/ ,. 67/5.(& &.6 /5>+>= 5>)>9(.'( />??(/+'9,.,'&9 />''(//:

":@A863 &0>25B7><C 4(5(.6,.? -. +<( '9,.,'&9 '-.6,+,-.

of the patient, an appropriate uid balance with special

&++(.+,-. +- +<( &6=,.,/+)&+,-. -0 6,>)(+,'/A &.+,'-&?>9&.+/A

+)(&+=(.+ -0 '-=-)*,6,+,(/ &.6 .>+),+,-.&9 &/5('+/ /<->96*( '-./,6()(6: U+ &99 +,=(/A <(&9+< '&)( 5)-8,6()/ /<->96

/+)-.?97 (.0-)'( /+),.?(.+ =(&/>)(/ &?&,./+ &'+,8(

',?&)(++( /=-M,.?: c,8(. +<&+ 5&+,(.+/ <-/5,+&9,E(6

*('&>/( -0 (%&'()*&+,-./ -0 1234 &)( &+ ,.')(&/(6 ),/M

-0 6((5 8(,. +<)-=*-/,/ &.6 5>9=-.&)7 (=*-9,/=Y\"AY\LA

+<)-=*-5)-5<79&'+,' =(&/>)(/ /<->96 *( (.<&.'(6Y\HDY\!:

':;NC?7@G?L /QNNG?@

(DE9>8 30>25BE= ;<,/ ,/ & M(7 '-=5-.(.+ -0 <-/5,+&9+)(&+=(.+ -0 &. (%&'()*&+,-.: G>559(=(.+&9 -%7?(. /<->96*( +,+)&+(6 +- ,=5)-8( +<( 5&+,(.+P/ <75-%(=,& I,+< & +&)?(+/&+>)&+,-. -0 TTDRHW!!H: 2.'( -%7?(. ,/ /+&)+(6A &)+(),&9*9--6 ?&/(/ /<->96 *( '<('M(6 Q"DZ" =,.>+(/ 9&+() +-(./>)( /&+,/0&'+-)7 -%7?(.&+,-. I,+<->+ '&)*-. 6,-%,6(retention or acidosis. Venturi masks (high-ow devices)-00() =-)( &''>)&+( &.6 '-.+)-99(6 6(9,8()7 -0 -%7?(. +<&.6- .&/&9 5)-.?/ *>+ &)( 9(// 9,M(97 +- *( +-9()&+(6 *7 +<(5&+,(.+HRL:

F>837;5312E /ABB123= G-=( 5&+,(.+/ .((6 ,==(6,&+(&6=,//,-. +- &. ,.+(./,8( '&)( >.,+ @V1fC @%789: (<TC:

U6=,//,-. -0 5&+,(.+/ I,+< /(8()( (%&'()*&+,-./ +-,.+()=(6,&+( -) /5(',&9 )(/5,)&+-)7 '&)( >.,+/ =&7 *(&55)-5),&+( ,0 5()/-..(9A /M,99/A &.6 (F>,5=(.+ (%,/+ +-,6(.+,07 &.6 =&.&?( &'>+( )(/5,)&+-)7 0&,9>)( />''(//0>997:

K(.+,9&+-)7 />55-)+ ,. &. (%&'()*&+,-. '&. *( 5)-8,6(6 *7(,+<() .-.,.8&/,8( @*7 .&/&9 -) 0&',&9 =&/MC -) ,.8&/,8(

8(.+,9&+,-. @*7 -)-D+)&'<(&9 +>*( -) +)&'<(-/+-=7C:i(/5,)&+-)7 /+,=>9&.+/ &)( .-+ )('-==(.6(6 0-) &'>+()(/5,)&+-)7 0&,9>)(HR":

%789: (<T< -BKCJ7@CGB; HG? -!U #KAC;;CGB O

Severe dyspnea that responds inadequately to initial emergencytherapy

Changes in mental status (confusion, lethargy, coma) Persistent or worsening hypoxemia (PaO

! < . kPa, 0 mmHg) and/or

severe/worsening respiratory acidosis (pH < 7.2) despite supplementaloxygen and noninvasive ventilation

eed for invasive mechanical ventilation

Hemodynamic instabilityneed for vasopressors!"#$%& ()*#+($)* ,))- .# /) $#,*0-)()-1

#1878G5<7G> H>6058765; G>837;53718= ;<( >/( -0

.-.,.8&/,8( =('<&.,'&9 8(.+,9&+,-. @OVKC <&/ ,.')(&/(6

signicantly over time among patients hospitalized for

&'>+( (%&'()*&+,-./ -0 1234: OVK <&/ *((. /+>6,(6

,. )&.6-=,E(6 '-.+)-99(6 +),&9/ /<-I,.? & />''(// )&+(

-0 T"DTYW !!QD!!ZAY!Q: OVK <&/ *((. /<-I. +- ,=5)-8(

&'>+( )(/5,)&+-)7 &',6-/,/ @,.')(&/(/ 5S &.6 6(')(&/(/

3&12HCA 6(')(&/( )(/5,)&+-)7 )&+(A I-)M -0 *)(&+<,.?A

/(8(),+7 -0 *)(&+<9(//.(//A '-=59,'&+,-./ />'< &/ 8(.+,9&+-)

&//-',&+(6 5.(>=-.,&A &.6 9(.?+< -0 <-/5,+&9 /+&7

@&MCK:BJ: #C: X-)( ,=5-)+&.+97A =-)+&9,+7 &.6 ,.+>*&+,-.

)&+(/ &)( )(6>'(6 *7 +<,/ ,.+()8(.+,-.!!!A!!\D!!R @&MCK:BJ: #C

%789: (<V />==&),E(/ +<( ,.6,'&+,-./ 0-) OVK!!Q:

8/16/2019 GOLD Report 2016


!! !"#"$%!%#& () %*"+%,-"&.(#/

%789: (<V< -BKCJ7@CGB; HG? .GBCBM7;CM:

3:JP7BCJ79 W:B@C97@CGB>X=YFF(YF(=YF(>

At least one of the following Respiratory acidosis (arterial pH 7. and/or PaCO

! ≥ 6.0 kPa,

mm Hg) Severe dyspnea with clinical signs suggestive of respiratory muscle

fatigue, increased work of breathing, or both, such as use of respiratoryaccessory muscles, paradoxical motion of the abdomen, or retraction ofthe intercostal spaces

%789: (<Z< -BKCJ7@CGB; HG? -BM7;CM: 3:JP7BCJ79 W:B@C97@CGB

Unable to tolerate IV or IV failure Respiratory or cardiac arrest Respiratory pauses with loss of consciousness or gasping for air Diminished consciousness, psychomotor agitation inadequately controlled

#$ %&'()*+, Massive aspiration Persistent inability to remove respiratory secretions Heart rate < 0 min-1 with loss of alertness

Severe hemodynamic instability without response to uids and vasoactive'-./%

Severe ventricular arrhythmias Life-threatening hypoxemia in patients unable to tolerate IV

.8G5<7G> H>6058765; G>837;53718= ;<( ,.6,'&+,-./0-) ,.,+,&+,.? ,.8&/,8( =('<&.,'&9 8(.+,9&+,-. 6>),.? &.(%&'()*&+,-. &)( /<-I. ,. %789: (<ZA &.6 ,.'9>6( 0&,9>)( -0 &.,.,+,&9 +),&9 -0 OVK!Y": U/ (%5(),(.'( ,/ *(,.? ?&,.(6 I,+< +<(?(.()&9,E(6 '9,.,'&9 >/( -0 OVK ,. 1234A /(8()&9 ,.6,'&+,-./0-) ,.8&/,8( =('<&.,'&9 8(.+,9&+,-. &)( *(,.? />''(//0>997+)(&+(6 I,+< OVKA &.6 ,. &99 *>+ & 0(I /,+>&+,-./ +<()( ,/.-+<,.? +- *( 9-/+ *7 & +),&9 -0 .-.,.8&/,8( 8(.+,9&+,-.!Y":

;<( >/( -0 ,.8&/,8( 8(.+,9&+,-. ,. 8()7 /(8()( 1234patients is inuenced by the likely reversibility of the5)(',5,+&+,.? (8(.+A 5&+,(.+P/ I,/<(/A &.6 &8&,9&*,9,+7 -0,.+(./,8( '&)( 0&',9,+,(/: e<(. 5-//,*9(A & '9(&) /+&+(=(.+-0 +<( 5&+,(.+P/ -I. +)(&+=(.+ I,/<(/j&. &68&.'(directive or living willmakes these difcult decisions=>'< (&/,() +- )(/-98(: X&_-) <&E&)6/ ,.'9>6( +<( ),/M-0 8(.+,9&+-)D&'F>,)(6 5.(>=-.,& @(/5(',&997 I<(. =>9+,D)(/,/+&.+ -)?&.,/=/ &)( 5)(8&9(.+CA *&)-+)&>=&A &.6 0&,9>)(+- I(&. +- /5-.+&.(->/ 8(.+,9&+,-.:

1-.+)&)7 +- /-=( -5,.,-./A &'>+( =-)+&9,+7 &=-.? 1234

5&+,(.+/ I,+< )(/5,)&+-)7 0&,9>)( ,/ 9-I() +<&. =-)+&9,+7

&=-.? 5&+,(.+/ 8(.+,9&+(6 0-) .-.D1234 '&>/(/!YQ:

4(/5,+( +<,/A +<()( ,/ (8,6(.'( +<&+ 5&+,(.+/ I<- =,?<+-+<()I,/( />)8,8( =&7 *( 6(.,(6 &6=,//,-. +- ,.+(./,8(

'&)( 0-) ,.+>*&+,-. *('&>/( -0 >.I&))&.+(6 5)-?.-/+,'

5(//,=,/=!Y!: U /+>67 -0 & 9&)?( .>=*() -0 1234 5&+,(.+/

I,+< &'>+( )(/5,)&+-)7 0&,9>)( )(5-)+(6 ,.D<-/5,+&9 =-)+&9,+7

-0 L\D!RW!"Q: J>)+<() 6(&+</ I()( )(5-)+(6 -8() +<(

.(%+ LH =-.+</A 5&)+,'>9&)97 &=-.? +<-/( 5&+,(.+/ I<-

<&6 5--) 9>.? 0>.'+,-. *(0-)( ,.8&/,8( 8(.+,9&+,-. @J$KL

` Q"W 5)(6,'+(6CA <&6 & .-.D)(/5,)&+-)7 '-=-)*,6,+7A -)

I()( <->/(*->.6: 3&+,(.+/ I<- 6,6 .-+ <&8( & 5)(8,->/97

6,&?.-/(6 '-=-)*,6,+7A <&6 )(/5,)&+-)7 0&,9>)( 6>( +- &

5-+(.+,&997 )(8()/,*9( '&>/( @/>'< &/ &. ,.0('+,-.CA -)

I()( )(9&+,8(97 =-*,9( &.6 .-+ >/,.? 9-.?D+()= -%7?(. 6,6

/>)5),/,.?97 I(99 &0+() 8(.+,9&+-)7 />55-)+:

%789: (<X< 1C;JP7?D: !?C@:?C7

Able to use long acting bronchodilators, either beta!-agonists and/

or anticholinergics with or without inhaled corticosteroids Inhaled short-acting beta

!-agonist therapy is required no more

frequently than every hrs Patient, if previously ambulatory, is able to walk across room Patient is able to eat and sleep without frequent awakening by

dyspnea Patient has been clinically stable for 12-2 hrs Arterial blood gases have been stable for 12-2 hrs Patient (or home caregiver) fully understands correct use of

medications Follow-up and home care arrangements have been completed

(e.g., visiting nurse, oxygen delivery, meal provisions) Patient, family, and physician are condent that the patient can

manage successfully at home

%789: (<=[< !P:J\9C;@ GH -@:A; @G

#;;:;; 7@ %CA: GH 1C;JP7?D: H?GA "G;NC@79

Assurance of effective home maintenance pharmacotherapyregimen

Reassessment of inhaler technique Education regarding role of maintenance regimen Instruction regarding completion of steroid therapy and antibiotics,

if prescribed Assess need for long-term oxygen therapy Assure follow-up visit in -6 weeks

Provide a management plan for comorbidities and their follow-up

%789: (<==< -@:A; @G #;;:;; 7@ 2G99G]SUN WC;C@

FST ^::\; #H@:? 1C;JP7?D: H?GA "G;NC@79

Ability to cope in usual environment Measurement of FEV

1

Reassessment of inhaler technique Understanding of recommended treatment regimen Reassess need for long-term oxygen therapy and/or home

nebulizer Capacity to do physical activity and activities of daily living CAT or mMRC Status of comorbidities

8/16/2019 GOLD Report 2016


!"#"$%!%#& () %*"+%,-"&.(#/ !Y

e(&.,.? -) 6,/'-.+,.>&+,-. 0)-= =('<&.,'&9 8(.+,9&+,-.

can be particularly difcult and hazardous in patients with

COPD. The most inuential determinant of mechanical

8(.+,9&+-)7 6(5(.6(.'7 ,. +<(/( 5&+,(.+/ ,/ +<( *&9&.'(

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pulmonary gas exchange by itself is not a major difculty,. 5&+,(.+/ I,+< 1234!YZD!YT: e(&.,.? 5&+,(.+/ 0)-= +<(

ventilator can be a very difcult and prolonged process

&.6 +<( *(/+ =(+<-6 @5)(//>)( />55-)+ -) & ;D5,('( +),&9C

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I),++(. &'+,-. 59&. ,.')(&/(/ &55)-5),&+( +<()&5(>+,',.+()8(.+,-./ 0-) &. (%&'()*&+,-.A &. (00('+ +<&+ 6-(/ .-+6(')(&/( <(&9+<D'&)( )(/->)'( >+,9,E&+,-.!\Q @&MCK:BJ: 6C*>+ =&7 /<-)+(. )('-8()7 +,=(!\!:

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.-+ &+ <,?< ),/M -0 67,.?: J->) )&.6-=,E(6 '9,.,'&9 +),&9/

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M.-I. &/ ]<-/5,+&9D&+D<-=(^ '&)(C )(5)(/(.+/ &. (00('+,8(

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)(/5,)&+-)7 0&,9>)(!Z\D!\"AY!! @&MCK:BJ: #C: S-I(8()A +<( (%&'+

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)(=&,. >.'()+&,. &.6 I,99 8&)7 *7 <(&9+< '&)( /(++,.?!ZRA!\":

;)(&+=(.+ )('-==(.6&+,-./ &)( +<( /&=( 0-) <-/5,+&9,E(6

5&+,(.+/: G>55-)+(6 /(90D=&.&?(=(.+ <&6 .- (00('+ -. +,=(

to rst readmission or death with COPDY!Y: U''>=>9&+,.?

6&+& 0)-= & 8&),(+7 -0 /+>6,(/ ,.6,'&+( +<&+ +(9(<(&9+< ,. &.7of its current forms has not shown benets for patients with

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cessation, inuenza and pneumococcal vaccines, knowledge

-0 '>))(.+ +<()&57 ,.'9>6,.? ,.<&9() +('<.,F>(A &.6 +)(&+=(.+

I,+< 9-.?D&'+,.? ,.<&9(6 *)-.'<-6,9&+-)/A I,+< -) I,+<->+,.<&9(6 '-)+,'-/+()-,6/A &.6 5-//,*97 5<-/5<-6,(/+()&/(D!

,.<,*,+-)/A &)( &99 +<()&5,(/ +<&+ )(6>'( +<( .>=*() -0

(%&'()*&+,-./ &.6 <-/5,+&9,E&+,-./LQQALQ!ALRYAHL!AHZ!AHZZ: U 9&)?(

=>9+,'(.+() /+>67 ,.6,'&+(6 +<&+ /,=8&/+&+,. <&/ .- ,=5&'+

-. (%&'()*&+,-. )&+(/Z"TAZHY: $&)97 ->+5&+,(.+ 5>9=-.&)7

)(<&*,9,+&+,-. &0+() <-/5,+&9,E&+,-. 0-) &. (%&'()*&+,-. ,/ /&0(

and results in clinically signicant improvements in exercise

'&5&',+7 &.6 <(&9+< /+&+>/ &+ Q =-.+</!\Y: 3&+,(.+/ /<->96

*( (.'->)&?(6 +- =&,.+&,. 5<7/,'&9 &'+,8,+7A &.6 &.%,(+7A

6(5)(//,-. &.6 /-',&9 5)-*9(=/ /<->96 *( 6,/'>//(6:

Principal caregivers should be identied if the patient has a

signicant persisting disability.

8/16/2019 GOLD Report 2016


!"#$%&'

(

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8/16/2019 GOLD Report 2016


!" $%&' ()' $%*%+,-'-.-/0

)&* $,-.%/0

• $%&' 12345 61478939 :83; 13;4< =894>949

(comorbidities) that may have a signicant impact on

prognosis.

• In general, the presence of comorbidities should not

alter COPD treatment and comorbidities should be

treated as if the patient did not have COPD.

• Cardiovascular disease is a major comorbidity in

COPD and probably both the most frequent and most

important disease coexisting with COPD.

• Osteoporosis and depression are also major

comorbidities in COPD, are often under-diagnosed,

and are associated with poor health status and

prognosis.• Lung cancer is frequently seen in patients with COPD

and has been found to be the most frequent cause of

death in patients with mild COPD.

• Gastroesophageal reux (GERD) is associated with

an increased risk of exacerbations and poorer health

status.

$%&' 12345 61478939 :83; 13;4< =894>949

(comorbidities) that may have a signicant impact

on prognosis?@@A?BCA?!DA!"EAC"FAE@G. Some of these ariseindependently of COPD whereas others may be causally

<4H>34=A 483;4< :83; 9;><4= <89I 2>631<9 1< JK 154 =894>94

actually increasing the risk of another. It is possible that

features of COPD, such as systemic inammation, are

shared with other diseases and as such this mechanism

represents a link between COPD and some of its

61L1<J8=83849!"". This risk of comorbid disease can be

increased by the sequelae of COPD; e.g., reduced physical

activity. Whether or not COPD and comorbid diseases

are related, management of the COPD patient must

include identication and treatment of its comorbidities.

Importantly, comorbidities with symptoms also associated

with COPD may be overlooked; e.g., heart failure and

lung cancer (breathlessness) or depression (fatigue

and reduced physical activity). Frequent and treatable

comorbidities should be prioritized.

$1L1<J8=83849 ><4 61LL15 >3 >5K 94M4<83K 12 $%&'?B?

and the differential diagnosis can often be difcult. For

example, in a patient with both COPD and heart failure an

exacerbation of COPD may be accompanied by worsening

of heart failure.

Below is a brief guide to management of COPD and somecomorbidities in stable disease. The recommendations

may be insufcient for the management of all patients

and cannot substitute for the use of guidelines for the

management of each comorbidity.

!1234561789:12 ;47<17< =!>;?

CVD is a major comorbidity in COPD and probably both

the most frequent and most important disease coexisting

:83; $%&'?BCA!"". Four separate entities within CVD will

be considered: ischemic heart disease, heart failure, atrial

brillation and hypertension.

+/012340 52678 $4/26/2 9+5$:; -N' 89 856<4>94= 85

COPD, to some extent because of an unfavourable IHD

risk prole in COPD patients!"FA!"G. There is evidence that

61561L83>53 $%&' 856<4>949 L1<J8=83K >5= L1<3>H83K

among patients with IHDE?@ and that myocardial injury is

overlooked and IHD is therefore under-diagnosed in COPD

patients!F@.

Treatment of IHD in patients with COPD: IHD should

be treated according to usual IHD guidelines, as there is

no evidence that IHD should be treated differently in the

presence of COPD. In a signicant proportion of patients

with IHD a beta-blocker will be indicated, either to treatangina or after a myocardial infarction. Treatment with

94H4638M4 J43>?-blockers is considered safe!F?AC!EAC"GACF@ but this

is based on relatively few short-term studies. The benets of

94H4638M4 J43>?-blockers when indicated in IHD are, however,

considerably larger than the potential risks associated with

treatment, even in patients with severe COPD.

Treatment of COPD in patients with IHD: COPD should

be treated as usual as there is no evidence that COPD

should be treated differently in the presence of IHD. This

statement is based on ndings from large long-term studies

85 $%&' >H154?GCAD?!A!FD, but no large long-term studies exist

in patients with both COPD and IHD. Although no studies

on COPD medications in patients with unstable angina

exist, it seems reasonable to avoid especially high doses of

beta-agonists.

52678 <64=>72 95<:; Heart failure is a common comorbidity

in COPD. Roughly 30% of patients with stable COPD

will have some degree of HF!FB, and worsening of HF is

a signicant differential diagnosis to an exacerbation of

!"#$%&' (0 !,$; #.; !,@,'A-;-%-&/

-.%',;B!%-,.

8/16/2019 GOLD Report 2016


$%&' ()' $%*%+,-'-.-/0 !F

COPD. Approximately 30% of patients in a HF clinic have

$%&'!F!, and comorbid COPD is often be the cause of

admission for acute HF!FC with signicant implications for

prognosis as FEV?is a strong predictor of mortality in HF!FE.

HF, COPD and asthma may be confused because of the

common cardinal symptom of breathlessness, and caution

89 :><<>534= 21< =8>O51989 >5= L>5>O4L453 12 3;494comorbidities.

Treatment of HF in patients with COPD: HF should

be treated according to usual HF guidelines as there

is no evidence that HF should be treated differently in

the presence of COPD. Treatment with selective beta?-

blockers has a signicant impact on survival in HF and

the presence of COPD is the most signicant reason for

patients not receiving sufcient therapy!F". However, as in

-N'A 3<4>3L453 :83; 94H4638M4 J43>?-blockers is considered

safe for heart failure patients who also have COPD!F?AC"GACF@.

Studies have shown that treatment with bisoprolol in HF

with concomitant COPD decreased FEV? but withoutdeleterious effects on symptoms and quality of life!FF >5=

3;>3 > 94H4638M4 J43>?-blocker is indeed preferable to a non-

selective beta-blocker in HF with COPD!FG. In a study of

patients with moderate-severe airow limitation and heart

failure (NYHA II), treatment with bisoprolol and carvedilol

was well tolerated and benecial effects on lung function

were seen. Bisoprolol was superior to carvedilol on

respiratory parametersC!". The benets of selective beta?-

blocker treatment in HF clearly outweigh any potential risk

associated with treatment even in patients with severe

COPD.

Treatment of COPD in patients with HF: COPD shouldbe treated as usual as there is no direct evidence that

COPD should be treated differently in the presence of

HF. As for IHD this statement is based on ndings from

large long-term studies in patients with HF and comorbid

$%&'?GCAD?!A!FD. An observational study found an increased

risk of death and hospital admission among patients with

HF treated with inhaled beta-agonists!G@, possibly indicating

a need for close follow-up of patients with severe HF who

are on this treatment for COPD.

&8746= <4?74==684@A 9&<:; Atrial brillation is the most

frequent cardiac arrhythmia and COPD patients have an

increased incidence of AF!G?. COPD with AF presents a

challenge to clinicians because of the breathlessness and

disability resulting from their coexistence.

Treatment of AF in patients with COPD: AF should be

treated according to usual AF guidelines, as there is no

evidence that patients with COPD should be treated

differently from all other patients. If beta-blockers are used,

J43>?-selective drugs are preferred (see considerations

under IHD and HF above).

Treatment of COPD in patients with AF: COPD should be

treated as usual; however, there are no good data on the

use of COPD medication in patients with AF and these

patients have often been excluded from clinical trials. It is

a clinical impression that care should be taken when using;8O; =1949 12 J43>D-agonists as this can make appropriate

heart rate control difcult.

5BC2782A/4@A; Hypertension is likely to be the most

frequently occurring comorbidity in COPD and has

implications for prognosis!"".

Treatment of hypertension in patients with COPD:

Hypertension should be treated according to usual

hypertension guidelines, as there is no evidence that

hypertension should be treated differently in the presence

of COPD. The role of treatment with selective beta-blockers

is less prominent in recent hypertension guidelines; if theseare used in patients with COPD, a selective beta

?-blocker

should be chosen.

Treatment of COPD in patients with hypertension: $%&'

should be treated as usual as there is no direct evidence

that COPD should be treated differently in the presence of

hypertension.

,7C<5D525747

Osteoporosis is a major comorbidity in COPD?BCA!""A 89

often under-diagnosed!GD and is associated with poor

health status and prognosis. Osteoporosis may be moreclosely associated with emphysema than other subgroups

12 $%&'!GB. Osteoporosis is more often associated with

=46<4>94= J1=K L>99 85=47!G! and low fat-free mass!GC.

Treatment of osteoporosis in patients with COPD:Osteoporosis should be treated according to usualosteoporosis guidelines. There is no evidence thatosteoporosis should be treated differently in the presenceof COPD.

Treatment of COPD in patients with osteoporosis: $%&'should be treated as usual, as there is no evidence that

stable COPD should be treated differently in the presenceof osteoporosis. Inhaled triamcinolone was associated withincreased loss of bone mass in the Lung Health Study II!GEAwhereas this was not the case for inhaled budesonide in3;4 /P+%0$%& 3<8>H?"C or for inhaled uticasone propionate85 3;4 .%+$N 3<8>HDC@. An association between inhaledcorticosteroids and fractures has been found in pharmaco-epidemiological studies; however, these studies have notfully taken severity of COPD or exacerbations and theirtreatment into account.

8/16/2019 GOLD Report 2016


!G $%&' ()' $%*%+,-'-.-/0

Systemic corticosteroids signicantly increase the riskof osteoporosis and recurrent courses of systemiccorticosteroids for COPD exacerbations should be avoidedif possible.

#EF4<CG 1E3 ;<D2<7745E

Anxiety and depression are major comorbidities in$%&'117,47-4 and both are associated with a poorprognosis!GFAC@@. Both are often associated with youngerage, female gender, smoking, lower FEV

?, cough, higher

SGRQ score, and a history of cardiovascular disease??"A!GG.

Treatment of anxiety and depression in patients with$%&'Q Both disorders should be treated according tousual guidelines, as there is no evidence that anxiety anddepression should be treated differently in the presence ofCOPD. Given the large number of patients who have bothdepression and COPD, more research on management ofdepression in COPD patients is neededC@?.

Treatment of COPD in patients with anxiety anddepression: COPD should be treated as usual as there isno evidence that stable COPD should be treated differentlyin the presence of anxiety and depression. The potentialimpact of pulmonary rehabilitation should be stressed asstudies have found that physical exercise has a benecialeffect on depression in generalC@D.

H9EI !1E8<2

Lung cancer is frequently seen in patients with COPD andhas been found to be the most frequent cause of death inpatients with mild COPDD?".

Treatment of lung cancer in patients with COPD: Lungcancer should be treated according to usual lung cancerguidelines, as there is no evidence that lung cancer shouldbe treated differently in the presence of COPD. However,often the reduced lung function of COPD patients will be afactor limiting surgical intervention for lung cancer.

Treatment of COPD in patients with lung cancer: $%&'should be treated as usual as there is no evidence thatstable COPD should be treated differently in the presenceof lung cancer.

-EJ<8C45E7

Serious infections, especially respiratory infections, arefrequently seen in patients with COPDC@B.

Treatment of infections in patients with COPD: *>6<1H8=4antibiotics increase the serum concentration oftheophylline. Apart from this, there is no evidence that

infections should be treated differently in the presenceof COPD. However, repeat courses of antibiotics forexacerbations may increase the risk for the presence of>538J81386 <49893>53 J>634<8>H 93<>859 >5= L1<4 4734598M4cultures of serious infections may be warranted.Treatment of COPD in patients with infections: $%&'should be treated as usual as there is no evidence thatstable COPD should be treated differently in the presenceof infections. In patients who develop repeated pneumonias:;8H4 15 85;>H4= 61<3861934<18=9A 3;89 L4=86>3815 L>K J4stopped in order to observe whether this medication couldbe the cause of repeated infections.

@<C1K5:48 /GE325L< 1E3 ;41K<C<7

Studies have shown that the presence of metabolicsyndrome and manifest diabetes are more frequent inCOPD and the latter is likely to impact on prognosis?!D.

Treatment of diabetes in patients with COPD: '8>J4349should be treated according to usual guidelines fordiabetes, as there is no evidence that diabetes should betreated differently in the presence of COPD. However, forpatients with severe COPD, it is not advised to aim for aJ1=K L>99 85=47 R,*-S H499 3;>5 D? IOTLD.

Treatment of COPD in patients with diabetes: $%&'should be treated as usual as there is no evidence thatstable COPD should be treated differently in the presenceof diabetes.

Gastroesophageal reux (GERD) is an independent risk2>631< 21< 47>64<J>38159 >5= 89 >99168>34= :83; :1<94health status. It is, thus a systemic comorbidity that mayhave an impact on the lungs. The mechanisms responsiblefor increased risk of exacerbations are not yet fullyestablished and may be more than simply acid reux.Proton pump inhibitors are often used for treatment ofGERD, but the most effective treatment for this condition in$%&' ;>9 K43 31 J4 493>JH89;4=E??. A25E8M4<8C1747

Persistent airow obstruction is a recognized feature ofsome patients with a primary diagnosis of bronchiectasis.However with increasing use of computed tomographyin the assessment of patients with COPD, the presenceof previously unrecognized radiographic bronchiectasisis being identiedCF?. This ranges from mild tubularbronchiectasis to more severe varicose change, althoughcystic bronchiectasis is uncommon. Whether thisradiological change has the same impact as patientswith a primary diagnosis of bronchiectasis remainsunknown at present, although it is associated with longer47>64<J>38159CFD >5= 856<4>94= L1<3>H83KCFB.

8/16/2019 GOLD Report 2016


$%&' ()' $%*%+,-'-.-/0 C@

Treatment of bronchiectasis in patients with COPD:

Treatment should be along conventional lines for

bronchiectasis with the addition of usual COPD strategies

where indicated. Whether prevention of exacerbations

requires more long-term use of oral or inhaled antibiotics

rather than bronchodilator or inhaled corticosteroid therapy

remains unknown.

Treatment of COPD in patients with bronchiectasis: $%&'

should be treated as usual, although some patients may

need more aggressive and prolonged antibiotic therapy.

-LD142<3 !5IE4C46< N9E8C45E

Impaired cognitive function is a feature of COPDE?DA >5=

COPD signicantly increases the risk of developing mild

cognitive impairmentE?B. Currently there is no evidence

for treatment benet in such patients, but they should be

<424<<4= 21< >99499L453 >5= 3<4>3L453 85 3;4 9>L4 :>K >9

patients with primary dementia.

8/16/2019 GOLD Report 2016


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9JM! 2',$ D @̂ ]*00$. X@ A'US.*/5*; )@ d*$+ D! E/06'.*;/% /- '</0,*%'5*/% /- 5*/5./6*B0 6+B; -/.0/5$./+ 5/ ;'+0$5$./+ 6+B;

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9M9! R/%$; OX@ X*++*5; 32@ PB.U$ OA@ E'+&$.+$C OQ! ?*;$';$severity and the effect of uticasone propionate on chronic/,;5.B<5*&$ 6B+0/%'.C F*;$';$ $e'<$.,'5*/%;! 34# ,(5-1# 6 9::J=9N(H`LIJ!

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9MM! Szafranski , Cukier A, Ramirez A, et al. Efcacy and;'-$5C /- ,BF$;/%*F$7-/.0/5$./+ *% 54$ 0'%'U$0$%5 /-<4./%*< /,;5.B<5*&$ 6B+0/%'.C F*;$';$! 34# ,(5-1# 6 9::J=9N(IML`N!

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H:M! T//U$%F//.% Q@ T//U$%&$$% 2]@ 2B55$%L&'% Qz+S$%QO@ d$;5,/ R@ ^$$%;5.' ]3! E';$ -'5'+*5C /- EYO?$e'<$.,'5*/%;( ' 0$5'L'%'+C;*; '%F ;5'5*;5*<'+ 0/F$++*%U'66./'<4! 34#K ,(5-1#K 6 ! 9:NN= JI( \:`v\N\!

H:\! O*bB$5 R@ E4'&'*++/% RLQ@ ?'&*F O@ Q'.5*% @̂ P+'%<4/% @̂2/<4$ V@ ^.$%<4 E/++$U$ /- #$%$.'+ T/;6*5'+ 2$;6*.'5/.CO4C;*<*'%; ZEOT#[! T*U4L.*;S 6'5*$%5; -/++/8*%U4/;6*5'+*;'5*/% -/. '% '<B5$ $e'<$.,'5*/% /- EYO?! 34#

,(5-1# 6 9:NJ= M9( KMHvK\\!

H:H! A*%U'%'C'U'0 )@ A<4$0,.* A@ E4'+0$.; R?! O.$F*<5/.;/- Q/.5'+*5C *% T/;6*5'+*>$F )FB+5; 8*54 )<B5$ ae'<$.,'5*/%/- E4./%*< Y,;5.B<5*&$ OB+0/%'.C ?*;$';$! ) AC;5$0'5*<2$&*$8 '%F Q$5'L'%'+C;*;! 700K 78K ?+"#)>K =">K 9:NJ=N:( `Nv`K!

H:I! #'.<*'L)C0$.*<4 R@ #x0$> Ô@ P$%$5 Q@ '̂..$./ a@Basagaa X, Gayete , et al. Identication and prospective&'+*F'5*/% /- <+*%*<'++C .$+$&'%5 <4./%*< /,;5.B<5*&$

6B+0/%'.C F*;$';$ ZEYO?[ ;B,5C6$;! ?+"#)F 9:NN= HH(MJ:vMJI!

H:`! E.*%$. #R@ E/%%$55 Ra@ )'./% A?@ )+,$.5 2D@ P'*+$C XE@E';',B.* 2@ $5 '+= EYO? E+*%*<'+ 2$;$'.<4 V$58/.S=E'%'F*'% W%;5*5B5$; /- T$'+54 2$;$'.<4! A*0&';5'5*% -/.54$ 6.$&$%5*/% /- $e'<$.,'5*/%; *% 0/F$.'5$L5/L;$&$.$EYO?! D 30/$ 6 :(% 9:NM RB% \=JI:Z9J[(99:NLN:!

8/16/2019 GOLD Report 2016


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H:K! Q*++$. R@ aF8'.F; 3?@ )UB;5r )@ P'SS$ O@ E'+&$.+$C OQ@E$++* P@ $5 '+! a&'+B'5*/% /- EYO? 3/%U*5BF*%'++C 5/ WF$%5*-CO.$F*<5*&$ AB../U'5$ a%F6/*%5; ZaE3WOAa[ W%&$;5*U'5/.;!Comorbidity, systemic inammation and outcomes in theaE3WOAa </4/.5! ,(5-1# :(% 9:NJ A$6=N:IZK[(NJIHL`M!

HN:! E'06/ #@ #B';5'./,' O@ Q'.>/<<4* )@ A'%5'.$++* )@ d'.'%*a@ d*U%'+* 3@ $5 '+! W06'<5 /- EYO? /% +/%UL5$.0 /B5</0$'-5$. A]L;$U0$%5 $+$&'5*/% 0C/<'.F*'+ *%-'.<5*/% .$<$*&*%U6.*0'.C 6$.<B5'%$/B; </./%'.C *%5$.&$%5*/%! 9+(5* 9:NJA$6=NMMZJ[(I\:LI!

HNN! Q'.5*%$> ET@ YS'G*0' c@ QB..'C A@ X';4S/ #2@ Q'.5*%$>^R@ A*+&$.0'% aD@ $5 '+!= EYO?#$%$ W%&$;5*U'5/.;!Impact of self-reported gastroesophageal reux disease*% ;B,G$<5; -./0 EYO?#$%$ </4/.5! ,(5-1# ,(5 9:NM RB%J=N\(H9!

HN9! ?/FF RX@ #$5/& Ad@ R/%$; OX! E/U%*5*&$ -B%<5*/% *%EYO?! 34# ,(5-1# 6 9:N:=J\ZM[(KNJL99!

HNJ! A*%U4 P@ Q*$+S$ QQ@ O'.;'*S )D@ E4' 2T@ 2/,$.5;2Y@ A<'%+/% O?@ $5 '+! ) 6./;6$<5*&$ ;5BFC /- <4./%*</,;5.B<5*&$ 6B+0/%'.C F*;$';$ '%F 54$ .*;S -/. 0*+F</U%*5*&$ *06'*.0$%5! 67:7 D(4#"$ 9:NM Q'C=INZ\[(\`NL`!

HNM! HNM( A4$ 3 c'%U O@ X'%U c@ i*% g@ ^'% 3 X'%U c@ #'/ #@3B/ #@ $5 '+! E4*%$;$ 8'5$.L6*6$ ;0/S*%U '%F 54$ .*;S /-<'6/! 9+(5* ! 9:NM Y<5=NMHZM[(K9MLJN!

HN\! 2'0*.$>Ld$%$U'; )@ A'%;/.$; 2T@ iB*%5'%'LE'..*++/

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HNI! D/% AA@ ?*+'&$. ?@ Q*55'+ Q@ V/+'% EQ@ E+'.S )3@ E'%'&'%

R3@ $5 '+! ]4$ E+*%*<'+ EYO? iB$;5*/%%'*.$( .$;6/%;$ 5/6B+0/%'.C .$4',*+*5'5*/% '%F 0*%*0'+ <+*%*<'++C *06/.5'%5F*--$.$%<$! ?+"#)F ! 9:NM A$6=HKZK[(IKJL`!

HN`! 2/;;* )@ #B$..*$./ Q@ E/..'F/ )= YO]WQY7)WOY A5BFC#./B6! X*54F.'8'+ /- *%4'+$F </.5*</;5$./*F; <'% ,$ ;'-$ *%EYO? 6'5*$%5; '5 +/8 .*;S /- $e'<$.,'5*/%( ' .$'+L+*-$ ;5BFC/% 54$ '66./6.*'5$%$;; /- 5.$'50$%5 *% 0/F$.'5$ EYO?6'5*$%5; ZYO]WQY[! ,(5-1# ,(5! 9:NM RB+ `=N\(II!

HNK! Dranseld MT, Feldman G, orenblat P, LaForce CF,Locantore , Pistolesi M, et al. Efcacy and safety of once-daily uticasone furoate/vilanterol (100/2 mcg) versustwice-daily uticasone propionate/salmeterol (20/0 mcg)*% EYO? 6'5*$%5;! ,(5-1# :(% ! 9:NM )BU=N:`Z`[(NNINLK!

H9:! E.*%$. #R@ P/B.,$'B R@ ?*$S$06$. 23@ YB$++$55$ ?2@#//F.*FU$ ?@ T$.%'%F$> O@ $5 '+! O.$&$%5*/% /- '<B5$$e'<$.,'5*/%; /- EYO?( )0$.*<'% E/++$U$ /- E4$;5O4C;*<*'%; '%F E'%'F*'% ]4/.'<*< A/<*$5C #B*F$+*%$!9+(5* ! 9:N\ )6.=NMIZM[(`KML9!

H9N! O cB ]@ ^'*% D@ P/CF EQ@ A*%U4 A@ X$*;; EY@ 3* ]@ $5 '+!Benets and harms of roumilast in moderate to severeEYO?! ]4/.'e! 9:NM RB+=HKZI[(HNHL99! U 9`( PB;<4 )Q@A</55LA4$+F/% 3)@ O*$.<$ R@ E4'55*++*/% a)@ EB%%*%U4'0D@ PB<S+$C Q3@ $5 '+! ?$6.$;;$F 0//F 6.$F*<5; 6B+0/%'.C.$4',*+*5'5*/% </06+$5*/% '0/%U 8/0$%@ ,B5 %/5 0$%!

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H99! PB;<4 )Q@ A</55LA4$+F/% 3)@ O*$.<$ R@ E4'55*++*/% a)@EB%%*%U4'0 D@ PB<S+$C Q3@ $5 '+! ?$6.$;;$F 0//F6.$F*<5; 6B+0/%'.C .$4',*+*5'5*/% </06+$5*/% '0/%U8/0$%@ ,B5 %/5 0$%! ,(5-1# :(% ! 9:NM RB+=N:`ZI[(N::ILNJ!

H9J! D/%$<%C ]@ O'.S Rc@ A/0$.; D2@ D/%$<%C ?@ Y.,'% Q@A/B<$S @̂ O'.S$. DY@ $5 '+! 2$+'5*/% /- <4./%*< /,;5.B<5*&$6B+0/%'.C F*;$';$ 5/ '5.*'+ '%F &$%5.*<B+'. '..4C540*';!

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H9\! W%U$,.*U5;$% ]A@ Q'./55 R3@ V/.F$;5U''.F P#@ 3'%U$O@ T'++'; R@ d$;5,/ R! A5'5*% B;$ '%F $e'<$.,'5*/%; *%*%F*&*FB'+; 8*54 <4./%*< /,;5.B<5*&$ 6B+0/%'.C F*;$';$!?+"#)F ! 9:N\ R'%=I:ZN[(JJLM:!

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+./01&2 34()05%/6!*+37

8/16/2019 GOLD Report 2016


"##$%&'( ")

!"#$%&'

Diagnosis Of Diseases Of Chronic Airow

(&)&*+*&,$- !/*0)+1 2345 +$% !/*0)+62345

37#89+" :;$%8,)#

! <,&$* "8,<#=* ,> ?@A! +$% ?3(5B

CDE 43@AF:

3GHD2F@ID

*+,- ./0-10-2-345-16 6/.27108 5,7- 8/ 5--,-8 .9,0,.,50- 8/:

• Identify patients who have a disease of chronic airow limitation

• &,-8,0;2,-+ 5-8+75 <=/7 >?#& 506 8+1 "-8+753>?#& ?@1=95A BC06=/71 D">?BE

• &1.,61 /0 ,0,8,59 8=1587108 506F/= 0116 </= =1<1==59

• &,-8,0;2,-+,0; 5-8+75 <=/7 >?#& .50 41 A=/491758,.G A5=8,.295=9C ,0 -7/H1=- 506 /961= 56298-

• ACOS is identied by the features that it shares with both asthma and COPD.

• " -81AI,-1 5AA=/5.+ 8/ 6,5;0/-,- ,- 56@,-16G ./7A=,-,0; =1./;0,8,/0 /< 8+1 A=1-10.1 /< 5

.+=/0,. 5,=I5C- 6,-15-1G -C06=/7,. .581;/=,J58,/0 5- 5-8+75G >?#& /= 8+1 /@1=95A 418I110

asthma and COPD (the Asthma COPD Overlap Syndrome (ACOS)), conrmation by spirom3

etry and, if necessary, referral for specialized investigations.

• "98+/2;+ ,0,8,59 =1./;0,8,/0 506 8=1587108 /< ">?B 75C 41 7561 ,0 A=,75=C .5=1G =1<1==59 </=conrmatory investigations is encouraged, as outcomes for ACOS are often worse than for

asthma or COPD alone.

• '0,8,59 8=1587108 -+/296 41 -191.816 8/ 10-2=1 8+58:

/ #58,108- I,8+ <1582=1- /< 5-8+75 =1.1,@1 561K2581 ./08=/991= 8+1=5AC ,0.926,0; ,0+5916

./=8,./-81=/,6-G 428 0/8 9/0;35.8,0; 4=/0.+/6,958/=- 59/01 D5- 7/0/8+1=5ACEG 506

/ #58,108- I,8+ >?#& =1.1,@1 5AA=/A=,581 -C7A8/758,. 8=1587108 I,8+ 4=/0.+/6,958/=- /=

combination therapy, but not inhaled corticosteroids alone (as monotherapy).

• *+1 ./0-10-2-345-16 61-.=,A8,/0 /< 8+1 "-8+75 >?#& ?@1=95A BC06=/71 D">?BE ,- ,081063

ed to stimulate further study of the character and treatments for this common clinical problem.

L *+,- .+5A81= 59-/ 5AA15=- ,0 8+1 M9/459 B8=581;C </= "-8+75 N505;17108 506 #=1@108,/0 OP)QG 5@5,95491 <=/7

http://www.ginasthma.org

8/16/2019 GOLD Report 2016


"O "##$%&'(

5DJ@A@F@3A:

Table 1. Current denitions of asthma and COPD, and clinical description of ACOS

" -2775=C /< 8+1 8CA,.59 .+5=5.81=,-8,.- /< 5-8+75G >?#& 506 ">?B ,- A=1-10816 ,0 *5491 O5G -+/I,0; 8+1 -,7,95=,8,1-

and differences in history and investigations.

:FD4KL@:D !44M3!2N F3 5@!?A3:@: 3J 4!F@DAF: L@FN MD:4@M!F3ME :EO4F3O:

Step 1 Does the patient have chronic airways disease

A rst step in diagnosing these conditions is to identify patients at risk of, or with signicant likelihood of having chronic

airways disease, and to exclude other potential causes of respiratory symptoms. This is based on a detailed medical

history, physical examination, and other investigations.3,22-24

*18(89&1 $8"#504

R1582=1- 8+58 -+/296 A=/7A8 ./0-,61=58,/0 /< .+=/0,. 5,=I5C- 6,-15-1 ,0.9261:

• History of chronic or recurrent cough, sputum production, dyspnea, or wheezing; or repeated acute lower respiratory

8=5.8 ,0<1.8,/0-

• Report of a previous doctor diagnosis of asthma or COPD

• History of prior treatment with inhaled medications

• History of smoking tobacco and/or other substances

• Exposure to environmental hazards, e.g. occupational or domestic exposures to airborne pollutants

,$4"89&1 /:&%8(&#85(

• May be normal

• Evidence of hyperination and other features of chronic lung disease or respiratory insufciency

• Abnormal auscultation (wheeze and/or crackles)

;&)8515<4

• N5C 41 0/=759G A5=8,.295=9C ,0 15=9C -85;1-

• "40/=759,8,1- /0 .+1-8 (3=5C /= >* -.50 DA1=</=716 </= /8+1= =15-/0- -2.+ 5- -.=110,0; </= 920; .503

cer), including hyperination, airway wall thickening, air trapping, hyperlucency, bullae or other features of

emphysema.

• N5C ,6108,<C 50 5981=058,@1 6,5;0/-,-G ,0.926,0; 4=/0.+,1.85-,-G 1@,610.1 /< 920; ,0<1.8,/0- -2.+ 5- 8241=3

culosis, interstitial lung diseases or cardiac failure.

!/*0)+

Asthma is a heterogeneous disease, usually characterized by chronic airway inammation. It is dened by the

+,-8/=C /< =1-A,=58/=C -C7A8/7- -2.+ 5- I+11J1G -+/=801-- /< 4=158+G .+1-8 8,;+801-- 506 ./2;+ 8+58 @5=C /@1=time and in intensity, together with variable expiratory airow limitation. GINA 2014

2345

COPD is a common preventable and treatable disease, characterized by persistent airow limitation that is usu3

ally progressive and associated with enhanced chronic inammatory responses in the airways and the lungs to

noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual pa3

tients. GOLD 2014O)

!/*0)+K2345 37#89+" :;$%8,)# P!23:Q 6 + %#/=8&"*&,$ >,8 =9&$&=+9 R/#

Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airow limitation with several features

usually associated with asthma and several features usually associated with COPD. ACOS is therefore identied

by the features that it shares with both asthma and COPD.

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390//(8(< =>/"#85((&80/"

N50C -.=110,0; K21-8,/005,=1- +5@1 4110 A=/A/-16 8/ +19A 8+1 .9,0,.,50 ,6108,<C,0; -24S1.8- 58 =,-H /< .+=/0,. 5,=I5C-

disease, based on the above risk factors and clinical features.OT3OU These questionnaires are usually context-specic, so

8+1C 5=1 0/8 01.1--5=,9C =191@508 8/ 599 ./208=,1- DI+1=1 =,-H <5.8/=- 506 ./7/=4,6 6,-15-1- 6,<<1=EG 8/ 599 A=5.8,.1 -188,0;-

and uses (population screening versus primary or secondary care), or to all groups of patients (case-nding versus self-

presenting with respiratory symptoms versus referred consultation). Examples of these questionnaires are provided onboth the GINA and GOLD websites.

:FD4 ST F0# /;$%8,)&= %&+U$,/&/ ,> +/*0)+1 2345 +$% !23: &$ +$ +%R9* "+*&#$*

M,@10 8+1 1V8108 /< /@1=95A 418I110 <1582=1- /< 5-8+75 506 >?#& D*5491 O5EG 8+1 5AA=/5.+ A=/A/-16 </.2-1- /0 8+1

features that are most helpful in distinguishing asthma and COPD (Table 2b).

&? !""/%@1/ #$/ A/&#>0/" #$&# A&.50 & )8&<(5"8" 5A &"#$%& 50 5A *+,-

R=/7 5 .5=1<29 +,-8/=C 8+58 ./0-,61=- 5;1G -C7A8/7- D,0 A5=8,.295= /0-18 506 A=/;=1--,/0G @5=,54,9,8CG -15-/059,8C /=

A1=,/6,.,8C 506 A1=-,-810.1EG A5-8 +,-8/=CG -/.,59 506 /..2A58,/059 =,-H <5.8/=- ,0.926,0; -7/H,0; +,-8/=CG A=1@,/2- 6,5;0/3

ses and treatment and response to treatment, the features favoring the diagnostic prole of asthma or of COPD can be

assembled. The check boxes in Table 2b can be used to identify the features that are most consistent with asthma and/or COPD. Note that not all of the features of asthma and COPD are listed, but only those that most easily distinguish

between asthma and COPD.

@? *5%2&0/ #$/ (>%@/0 5A A/&#>0/" 8( A&.50 5A & )8&<(5"8" 5A &"#$%& 50 & )8&<(5"8" 5A *+,-

From Table-2b, count the number of checked boxes in each column. Having several (three or more) of the features listed

</= 1,8+1= 5-8+75 /= </= >?#&G ,0 8+1 54-10.1 /< 8+/-1 </= 8+1 5981=058,@1 6,5;0/-,-G A=/@,61- 5 -8=/0; 9,H19,+//6 /< 5

correct diagnosis.OU However, the absence of any of these features has less predictive value, and does not rule out the

diagnosis of either disease. For example, a history of allergies increases the probability that respiratory symptoms are

621 8/ 5-8+75G 428 ,- 0/8 1--108,59 </= 8+1 6,5;0/-,- /< 5-8+75 -,0.1 0/035991=;,. 5-8+75 ,- 5 I1993=1./;0,J16 5-8+75

phenotype; and atopy is common in the general population including in patients who develop COPD in later years. When

a patient has similar numbers of features of both asthma and COPD, the diagnosis of ACOS should be considered.

9? *5("8)/0 #$/ 1/./1 5A 9/0#&8(#4 &05>() #$/ )8&<(5"8" 5A &"#$%& 50 *+,-B 50 C$/#$/0 #$/0/ &0/ A/&#>0/" 5A @5#$

"><</"#8(< !"#$%&D*+,- +./01&2 34()05%/

'0 8+1 54-10.1 /< A58+/;0/7/0,. <1582=1-G .9,0,.,50- =1./;0,J1 8+58 6,5;0/-1- 5=1 7561 /0 8+1 I1,;+8 /< 1@,610.1G A=/3

vided there are no features that clearly make the diagnosis untenable. Clinicians are able to provide an estimate of their

level of certainty and factor it into their decision to treat. Doing so consciously may assist in the selection of treatment

and, where there is signicant doubt, it may direct therapy towards the safest option - namely, treatment for the condition

that should not be missed and left untreated.

8/16/2019 GOLD Report 2016


8/16/2019 GOLD Report 2016


"T "##$%&'(

:FD4 X- :"&8,)#*8;

Spirometry is essential for the assessment of patients with suspected chronic disease of the airways. It must be per 3

formed at either the initial or a subsequent visit, if possible before and after a trial of treatment. Early conrmation or

exclusion of the diagnosis may avoid needless trials of therapy, or delays in initiating other investigations. Spirometry

conrms chronic airow limitation but is of more limited value in distinguishing between asthma with xed airow obstruc3

tion, COPD and ACOS (Table 3).

Measurement of peak expiratory ow (PEF), although not an alternative to spirometry, if performed repeatedly on the

same meter over a period of 12 weeks may help to conrm the diagnosis of asthma by demonstrating excessive vari3

ability, but a normal PEF does not rule out either asthma or COPD. A high level of variability in lung function may also be

found in ACOS.

"<81= 8+1 =1-298- /< -A,=/718=C 506 /8+1= ,0@1-8,;58,/0- 5=1 5@5,95491G 8+1 A=/@,-,/059 6,5;0/-,- <=/7 8+1 -C06=/71345-16

assessment must be reviewed and, if necessary, revised. As shown in Table 3, spirometry at a single visit is not always

conrmatory of a diagnosis, and results must be considered in the context of the clinical presentation, and whether

treatment has been commenced. Inhaled corticosteroids and long-acting bronchodilators inuence results, particularly

if a long withhold period is not used prior to performing spirometry. Further tests might therefore be necessary either to

conrm the diagnosis or to assess the response to initial and subsequent treatment.

:FD4 Y- 2,))#$=# &$&*&+9 *0#8+";

Faced with a differential diagnosis equally balanced between asthma and COPD (i.e. ACOS) the default position should

be to start treatment accordingly for asthma (Table 4). This recognizes the pivotal role of ICS in preventing morbidity and

1@10 6158+ ,0 A58,108- I,8+ 20./08=/9916 5-8+75 -C7A8/7-G </= I+/7 1@10 -117,0;9C Y7,96Z -C7A8/7- D./7A5=16 8/

those of moderate or severe COPD) might indicate signicant risk of a life-threatening attack)P.

• If the syndromic assessment suggests asthma or ACOS, or there is signicant uncertainty about the diagnosis of

COPD, it is prudent to start treatment as for asthma until further investigation has been performed to conrm or

refute this initial position.

o Treatments will include an ICS (in a low or moderate dose, depending on level of symptoms).

o A long-acting beta2-agonist (LABA) should also be continued (if already prescribed), or added. However, it

is important that patients should not be treated with a LABA without an ICS (often called LABA monotherapy)

if there are features of asthma.• '< 8+1 -C06=/7,. 5--1--7108 -2;;1-8- >?#&G 5AA=/A=,581 -C7A8/758,. 8=1587108 I,8+ 4=/0.+/6,958/=- /= ./74,053

tion therapy should be commenced, but not ICS alone (as monotherapy).O)

• *=1587108 /< ">?B -+/296 59-/ ,0.9261 56@,.1 54/28 /8+1= 8+1=5A128,. -8=581;,1-)\ ,0.926,0;:

/ B7/H,0; .1--58,/0 / #297/05=C =1+54,9,858,/0

/ [5..,058,/0-

o Treatment of comorbidities, as advised in the respective GINA and GOLD reports.

'0 5 75S/=,8C /< A58,108-G 8+1 ,0,8,59 7505;17108 /< 5-8+75 506 >?#& .50 41 -58,-<5.8/=,9C .5==,16 /28 58 A=,75=C .5=1

level. However, both the GINA and GOLD strategy reports make provision for referral for further diagnostic procedures

at relevant points in patient management (see Step 5). This may be particularly important for patients with suspected

ACOS, given that it is associated with worse outcomes and greater health care utilization.

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"\ "##$%&'(

F+V9# XT :"&8,)#*8&= )#+/R8#/ &$ +/*0)+1 2345 +$% !23:

:"&8,)#*8&= 7+8&+V9# !/*0)+ 2345 !23:

%/=759 R$[)FR[> A=13 /=

post BD

>/7A58,491 I,8+ 6,5;0/-,- %/8 ./7A58,491 I,8+ 6,5;3

0/-,-

%/8 ./7A58,491 2091--

/8+1= 1@,610.1 /< .+=/0,.

airow limitation

Post-BD FEV)/FVC <0.7 Indicates airow limitation

428 75C ,7A=/@1 -A/085013

/2-9C /= /0 8=1587108

Required for diagnosis

(GOLD)

W-2599C A=1-108

R$[) ≥0% predicted >/7A58,491 I,8+ 6,5;0/-,-

D;//6 5-8+75 ./08=/9 /= ,03

81=@59 418I110 -C7A8/7-E

Compatible with GOLD

classication of mild airow

9,7,858,/0 D.581;/=,1- " /=

B) if post- BD FEV)FR[>

<0.7

>/7A58,491 I,8+ 6,5;0/-,-

/< 7,96 ">?B

R$[) <0% predicted >/7A58,491 I,8+ 6,5;0/3

sis. Risk factor for asthma

1V5.1=458,/0-

"0 ,06,.58/= /< -1@1=,8C /<

airow limitation and risk of

future events (e.g. mortality

506 >?#& 1V5.1=458,/0-E

"0 ,06,.58/= /< -1@1=,8C /<

airow limitation and risk of

future events (e.g. mortality

506 1V5.1=458,/0-E

Post-BD increase in FEV)

12% and 200 ml from

baseline (reversible airow

9,7,858,/0E

W-259 58 -/71 8,71 ,0

./2=-1 /< 5-8+75G 428 75C

0/8 41 A=1-108 I+10 I1993

./08=/9916 /= /0 ./08=/991=-

>/77/0 506 7/=1 9,H19C

I+10 R$[) ,- 9/IG 428

">?B -+/296 59-/ 41 ./03

-,61=16

>/77/0 506 7/=1 9,H19C

I+10 R$[) ,- 9/IG 428

">?B -+/296 59-/ 41 ./03

-,61=16

Post-BD increase in FEV)

12% and 400ml from

45-19,01 D75=H16 =1@1=-3

,4,9,8CE

High probability of asthma Unusual in COPD. Con3

-,61= ">?B

>/7A58,491 I,8+ 6,5;0/-,-

/< ">?B

ACOS: asthma-COPD overlap syndrome; BD: bronchodilator; FEV1: forced expiratory volume in 1 second; FVC: forced

vital capacity; GOLD: Global Initiative for Obstructive Lung Disease.

:FD4 Z- M#>#88+9 >,8 /"#=&+9&[#% &$7#/*&U+*&,$/ P&> $#=#//+8;Q

Referral for expert advice and further diagnostic evaluation is necessary in the following contexts:

• Patients with persistent symptoms and/or exacerbations despite treatment.

• Diagnostic uncertainty, especially if an alternative diagnosis (e.g. bronchiectasis, post-tuberculous scarring, bronchiol3

itis, pulmonary brosis, pulmonary hypertension, cardiovascular diseases and other causes of respiratory symptoms)

needs to be excluded.

• Patients with suspected asthma or COPD in whom atypical or additional symptoms or signs (e.g. haemoptysis, sig3

nicant weight loss, night sweats, fever, signs of bronchiectasis or other structural lung disease) suggest an additional

pulmonary diagnosis. This should prompt early referral, without necessarily waiting for a trial of treatment for asthma

or COPD.

• When chronic airways disease is suspected but syndromic features of both asthma and COPD are few.

• Patients with comorbidities that may interfere with the assessment and management of their airways disease.

• Referral may also be appropriate for issues arising during on-going management of asthma, COPD or ACOS, as out3

lined in the GINA and GOLD strategy reports.

Table 5 summarizes specialized investigations that may be used to distinguish asthma and COPD.

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Table 4. Summary of syndromic approach to diseases of chronic airow limitation

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A APPENDIX

F+V9# ZT :"#=&+9&[#% &$7#/*&U+*&,$/ /,)#*&)#/ R/#% &$ %&/*&$UR&/0&$U +/*0)+ +$% 2345

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"##$%&'( "]

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