Gold COPD guideline 2024 . A review on change in guideline by GOLD .

A review on Gold COPD guideline revised in 2024 . This was presented in medicine ward in CIMCH , Chittagong .

1. Global Initiative For Chronic Obstructive Pulmonary Disease. Dr.Diptta Bhattacharjee IMO ,medicine dept CIMCH

2. What's new !

3. DEFINITION: Chronic obstructive pulmonary disease is a heterogenous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production and/or exacerbations) due to abnormalities of airways (bronchitis , bronchiolitis) and/or alveoli ( emphysema ) that cause persistent, often progressive, airflow obstruction.

4. Taxonomy :

5. DIAGNOSTIC CRITERIA: The presence of non-fully reversible airflow obstruction ( FEV1/FVC < 0.7 post bronchodilation measured by spirometry confirm the diagnosis of COPD.

6. Some individuals may present with structural lung lesions ( eg : emphysema ) and or physiological abnormalities ( including low FEV1 , gas trapping , hyperinflation , reduced lung diffusing capacity and/or rapid FEV1 decline ) without airflow obstruction ( FEV1 / FVC >= 0.7 post bronchodilation. These subjects are labelled as Pre – COPD . The term PRISm ( preserved ratio impaired spirometry ) implies to those with normal ratio but abnormal spirometry.

7. Pre bronchodilator Spirometry

8. Clinical indicators:

9. Diagnosis and assessment :

10. Screening and case finding:

11. Initial assessment:

12. Severity assessment tools:

13. Additional tests: Physiological tests : lung volumes Dlco ( carbon monoxide diffusing capacity of the lungs) Oximetry and arterial blood gas measurement Exercise testing and assessment of physical activity Imaging : chest X-ray Computed tomography Interstitial lung abnormalities Alpha 1 anti-trypsin deficiency Composite score Biomarkers Treatable traits

14. Prevention and management of COPD.

15. Smoking cessation: Pharmacological treatments for smoking cessation include controller medications aimed at achieving long term abstinence ( nortryptilin ,nicotine patch , bupropion and varenicline ) and those that rapidly relieve acute withdrawal symptoms.

16. Vaccination recommendation:

17. Pharmacological management of stable COPD:

18. Non-pharmacological treatment for stable COPD PATIENT GROUP ESSENTIAL RECOMMENDED DEPENDING ON LOCAL GUIDELINES A Smoking cessation (can include pharmacological treatment ) Physical activity Influenza vaccination COVID-19 vaccination Pneumococcal vaccination Pertussis vaccination Shingles vaccination RSV vaccination B and E Smoking cessation (can include pharmacological treatment ) Pulmonary rehabilitation Physical activity Influenza vaccination COVID-19 vaccination Pneumococcal vaccination Pertussis vaccination Shingles vaccination RSV vaccination

19. Rehabilitation, education and self-management PULMONARY REHABILITATION : Assessment and follow-up of pulmonary rehabilitation: Assessment should include: Detail history and physical examination Measurement of post-bronchodilator spirometry Assessment of exercise capacity Measurement of health status and impact of breathlessness Assessment of inspiratory and expiratory muscle strength and lower limb strength in patients who suffer from muscle wasting Discussion about individual patient goals and expectations .

20. OXYGEN THERAPY AND VENTILATORY SUPPORT

21. Oxygen Therapy and Ventilatory Support in Stable COPD: OXYGEN THERAPY The long term administration of oxygen Increases survival in patients with severe chronic resting hypoxemia . In patients with stable COPD and Moderate resting or exercise induced arterial desaturation, prescription of long- term oxygen therapy does not lengthen time to death or first hospitalization or provide sustained benefit in health status. Resting oxygenation at sea level does not exclude the development of severe hypoxemia during travelling by air . VENTILATORY SUPPORT NPPV may improve hospitalization free survival in selected patients after recent hospitalization, particularly in those with pronounced persistent daytime hypercapnia (PaCO2> 53 mmhg ) In patients with severe chronic hypercapnia and a history of hospitalization for acute respiratory failure, long term noninvasive ventilation may be considered.

22. Long term oxygen therapy LTOT is indicated for stable patients who have : PaO2 at or below 55 mmHg ( 7.3 kPa ) and 60 mmHg ( 8 kPa) , or SaO2 at or below 88% with or without hypercapnia confirmed twice over a 3 weeks period. PaO2 between 55 mmHg (7.3 kPa) and 60mmHg (8 kPa) , or SaO2 of 88% if there is evidence of pulmonary HTN, peripheral odema suggesting congestive cardiac failure , or polycythemia (HCT > 55%) .

23. Therapeutic interventions that reduce COPD mortality

24. Bronchodilators in stable COPD Inhaled bronchodilators in COPD are central to symptom management and commonly given on a regular basis to prevent or reduce symptoms . Inhaled bronchodilators are recommended over oral bronchodilators . Regular and as needed use of SABA or SAMA improves FEV1 and symptoms . Combinations of SABA and SAMA are superior compared to either medication alone in improving FEV1 and symptoms. LABA and LAMA are preferred over short acting agents except for patients with only occasional dyspnea and for immediate relief of symptoms in patients already on long -acting bronchodilators for maintenance therapy. LABA and LAMA significantly improve lung function , dyspnea , health status , and reduce exacerbation rates . LAMAs have a greater evidence of on exacerbation reduction compared with LABAs and decrease hospitalizations. When initiating treatment with long -acting bronchodilators the preferred choice is a combination of LABA + LAMA. In patients with persistence dyspnea on a single long -acting bronchodilator treatment should be escalated to two . Combination treatment with a LABA and a LAMA increases FEV1 and reduces symptoms compared to monotherapy . Combination treatment with LABA+ LAMA reduces exacerbations compared to monotherapy.

25. Anti-inflammatory therapy in stable COPD Inhaled corticosteroids Oral glucocorticoids PDE4 inhibitors ( Roflumilast) Antibiotics Mucoregulators and anti-oxidant agents Other anti-inflammatory – statin therapy

26. Other pharmacological treatments

27. Interventional and surgical therapies for COPD SYMPTOMS CHRONIC MUCUS PRODUCTION EXACERBATIONS DYSPNEA DISORDERS Chronic bronchitis Acute and chronic bronchitis Bulla Emphysema Tracheobronchomalacia Bulla Emphysema Tracheobronchomalacia SURGICAL AND BRONCOSCOPIC INTERVENTIONS Nitrogen cryospray Rheoplasty Targeted lung denervation Giant bullectomy Large airways stenting EBV Coil Thermal vapor ablation Lung sealants LVRS Lung transplantation

28. Management of Exacerbations

29. Definition: An exacerbation of COPD is defined as an event characterized by dypnea and /or cough and sputum that worsen over less than 14 days. Exacerbations of COPD are often associated with increased local and systemic inflammation caused by airway infection , pollution, or other insults to the lungs.

30. Confounders or contributors to be considered in patients presenting with suspected COPD exacerbations: MOST FREQUENT : Pneumonia Pulmonary embolism Heart failure LESS FREQUENT: Pneumothorax Pleural effusion Myocardial infarction and/or cardiac arrythmias

31. Indications for Respiratory or Medical Intensive Care Unit Admission :

32. Indications for Noninvasive Mechanical Ventilation (NIV) At least one of the following : Respiratory acidosis (PaCO2 >=6.0kPa or 45 mmHg and arterial pH <= 7.35) Severe dyspnea with clinical signs suggestive of respiratory muscle fatigue , increased work of breathing , or both, such as use of respiratory accessory muscles, paradoxical motion of the abdomen , or retraction of the intercostal spaces. Persistent hypoxemia despite supplemental oxygen therapy.

33. Indications for Invasive Mechanical Ventilation

34. COPD and Comorbidities

35. COPD AND COMORBIDITIES:

36. COVID 19 & COPD

37. Take home message.

38. Thank you