GOLD(COPD指南)2006

POCKET GUIDE TO COPD DIAGNOSIS, MANAGEMENT, AND PREVENTION A Guide for Health Care Professionals REVISED DECEMBER 2006 Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Chronic Obstructive Lung Disease POCKET_GUIDE_06 1/8/07 1:53 PM Page cov1 GOLD Executive Committee A. Sonia Buist, MD, US, Chair Antonio Anzueto, MD, US (representing ATS) Peter Calverley, MD, UK Teresita S. DeGuia, MD, Philippines Yoshinosuke Fukuchi, MD, Japan (representing APSR) Christine Jenkins, MD, Australia Nikolai Khaltaev, MD, Switzerland (representing WHO) James Kiley, PhD, US (representing NHLBI) Ali Kocabas, MD, Turkey Mara Victorina Lopez, MD, Uruguay (representing ALAT) Klaus F. Rabe, MD, PhD, Netherlands Roberto Rodriguez-Roisin, MD, Spain Thys van der Molen, MD, Netherlands Chris van Weel, MD, Netherlands (representing WONCA) GOLD National Leaders Representatives from many countries serve as a network for the dissemination and implementation of programs for diagnosis, management, and prevention of COPD. The GOLD Executive Committee is grateful to the many GOLD National Leaders who participated in discussions of concepts that appear in GOLD reports, and for their comments during the review of the 2006 Global Strategy for the Diagnosis, Management, and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease Pocket Guide to COPD Diagnosis, Management, and Prevention POCKET_GUIDE_06 1/8/07 1:53 PM Page 1 TABLE OF CONTENTS PREFACE KEY POINTS WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)? RISK FACTORS: WHAT CAUSES COPD? DIAGNOSING COPD Figure 1: Key Indicators for Considering a COPD Diagnosis Figure 2: Normal Spirogram and Spirogram Typical of Patients with Mild to Moderate COPD Figure 3: Differential Diagnosis of COPD COMPONENTS OF CARE: A COPD MANAGEMENT PROGRAM Component 1: Assess and Monitor Disease Component 2: Reduce Risk Factors Figure 4: Strategy to Help a Patient Quit Smoking Component 3: Manage Stable COPD Patient Education Pharmacologic Treatment Figure 5: Commonly Used Formulations of Drugs for COPD Non-Pharmacologic Treatment Figure 6: Therapy at Each Stage of COPD Component 4: Manage Exacerbations How to Assess the Severity of an Exacerbation Home Management Hospital Management Figure 7: Indications for Hospital Admission for Exacerbations APPENDIX I: SPIROMETRY FOR DIAGNOSIS OF COPD 3 5 6 7 8 12 13 15 17 22 24 POCKET_GUIDE_06 1/8/07 1:53 PM Page 2 3 Chronic Obstructive Pulmonary Disease (COPD) is a major cause of chronic morbidity and mortality throughout the world. The Global Initiative for Chronic Obstructive Lung Disease was created to increase awareness of COPD among health professionals, public health authorities, and the general public, and to improve prevention and management through a concerted worldwide effort. The Initiative prepares scientific reports on COPD, encourages dissemination and adoption of the reports, and promotes international collaboration on COPD research. While COPD has been recognized for many years, public health officials are concerned about continuing increases in its prevalence and mortality, which are due in large part to the increasing use of tobacco products worldwide and the changing age structure of populations in developing countries. The Global Initiative for Chronic Obstructive Lung Disease offers a framework for management of COPD that can be adapted to local health care systems and resources. Educational tools, such as laminated cards or computer-based learning programs, can be prepared that are tailored to these systems and resources. The Global Initiative for Chronic Obstructive Lung Disease program includes the following publications: • Global Strategy for the Diagnosis, Management, and Prevention of COPD. Scientific information and recommendations for COPD programs. (November 2006) • Executive Summary, Global Strategy for the Diagnosis, Management, and Prevention of COPD. (December 2006) • Pocket Guide to COPD Diagnosis, Management, and Prevention. Summary of patient care information for primary health care professionals. (December 2006) • What You and Your Family Can Do About COPD. Information booklet for patients and their families. PREFACE POCKET_GUIDE_06 1/8/07 1:53 PM Page 3 4 These publications are available on the Internet at http://www.goldcopd.org. This site provides links to other websites with information about COPD. This Pocket Guide has been developed from the Global Strategy for the Diagnosis, Management, and Prevention of COPD (2006). Technical discussions of COPD and COPD management, evidence levels, and specific citations from the scientific literature are included in that source document. Acknowledgements: Grateful acknowledgement is given for the educational grants from Altana Pharma, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Merck, Sharp & Dohme, Mitsubishi-Tokyo, Novartis, Pfizer, and Schering-Plough. The generous contributions of these companies assured that the workshop participants could meet together and publications could be printed for wide distribution. The workshop participants, however, are solely responsible for the statements and conclusions in the publications. POCKET_GUIDE_06 1/8/07 1:53 PM Page 4 5 KEY POINTS • Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extra- pulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. • Worldwide, the most commonly encountered risk factor for COPD is cigarette smoking. At every possible opportunity individuals who smoke should be encouraged to quit. In many countries, air pollution resulting from the burning of wood and other biomass fuels has also been identified as a COPD risk factor. • A diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. The diagnosis should be confirmed by spirometry. • A COPD management program includes four components: assess and monitor disease, reduce risk factors, manage stable COPD, and manage exacerbations. • Pharmacologic treatment can prevent and control symptoms, reduce the frequency and severity of exacerbations, improve health status, and improve exercise tolerance. • Patient education can help improve skills, ability to cope with illness, and health status. It is an effective way to accomplish smoking cessation, initiate discussions and understanding of advance directives and end-of-life issues, and improve responses to acute exacerbations. • COPD is often associated with exacerbations of symptoms. POCKET_GUIDE_06 1/8/07 1:53 PM Page 5 WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)? Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The air- flow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. This definition does not use the terms chronic bronchitis and emphysema* and excludes asthma (reversible airflow limitation). Symptoms of COPD include: • Cough • Sputum production • Dyspnea on exertion Episodes of acute worsening of these symptoms often occur. *Chronic bronchitis, defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years, is not necessarily associated with airflow limitation. Emphysema, defined as destruction of the alveoli, is a pathological term that is sometimes (incorrectly) used clinically and describes only one of several structural abnormalities present in patients with COPD. 6 Chronic cough and sputum production often precede the development of airflow limitation by many years, although not all individuals with cough and sputum production go on to develop COPD. POCKET_GUIDE_06 1/8/07 1:53 PM Page 6 7 RISK FACTORS: WHAT CAUSES COPD? Worldwide, cigarette smoking is the most commonly encountered risk factor for COPD. The genetic risk factor that is best documented is a severe hereditary deficiency of alpha-1 antitrypsin. It provides a model for how other genetic risk factors are thought to contribute to COPD. COPD risk is related to the total burden of inhaled particles a person encounters over their lifetime: • Tobacco smoke, including cigarette, pipe, cigar, and other types of tobacco smoking popular in many countries, as well as environmental tobacco smoke (ETS) • Occupational dusts and chemicals (vapors, irritants, and fumes) when the exposures are sufficiently intense or prolonged • Indoor air pollution from biomass fuel used for cooking and heating in poorly vented dwellings, a risk factor that particularly affects women in developing countries • Outdoor air pollution also contributes to the lungs’ total burden of inhaled particles, although it appears to have a relatively small effect in causing COPD. In addition, any factor that affects lung growth during gestation and childhood (low birth weight, respiratory infections, etc.) has the potential for increasing an individual’s risk of developing COPD. POCKET_GUIDE_06 1/8/07 1:53 PM Page 7 DIAGNOSING COPD A diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease, especially cigarette smoking (Figure 1). The diagnosis should be confirmed by spirometry* (Figure 2, page 9 and Appendix I, page 24). *Where spirometry is unavailable, the diagnosis of COPD should be made using all available tools. Clinical symptoms and signs (abnormal shortness of breath and increased forced expira- tory time) can be used to help with the diagnosis. A low peak flow is consistent with COPD but has poor specificity since it can be caused by other lung diseases and by poor performance. In the interest of improving the accuracy of a diagnosis of COPD, every effort should be made to provide access to standardized spirometry. 8 Figure 1: Key Indicators for Considering a COPD Diagnosis Consider COPD, and perform spirometry, if any of these indicators are present in an individual over age 40. These indicators are not diagnostic themselves, but the presence of multiple key indicators increasees the probability of a diagnosis of COPD. • Dyspnea that is: Progressive (worsens over time). Usually worse with exercise. Persistent (present every day). Described by the patient as an “increased effort to breathe,” “heaviness,” “air hunger,” or “gasping.” • Chronic cough: May be intermittent and may be unproductive. • Chronic sputum production: Any pattern of chronic sputum production may indicate COPD. • History of exposure to risk factors: Tobacco smoke (including popular local preparations). Occupational dusts and chemicals. Smoke from home cooking and heating fuel. POCKET_GUIDE_06 1/8/07 1:53 PM Page 8 When performing spirometry, measure: • Forced Vital Capacity (FVC) and • Forced Expiratory Volume in one second (FEV1). Calculate the FEV1/FVC ratio. Spirometric results are expressed as % Predicted using appropriate normal values for the person’s sex, age, and height. 9 Patients with COPD typically show a decrease in both FEV1 and FEV1/FVC. The degree of spirometric abnormality generally reflects the severity of COPD. However, both symptoms and spirometry should be considered when developing an individualized management strategy for each patient. Figure 2: Normal Spirogram and Spirogram Typical of Patients with Mild to Moderate COPD* *Postbronchodilator FEV1 is recommended for the diagnosis and assessment of severity of COPD. POCKET_GUIDE_06 1/8/07 1:53 PM Page 9 Stages of COPD Stage I: Mild COPD - Mild airflow limitation (FEV1/FVC < 70%; FEV1 ≥ 80% predicted) and sometimes, but not always, chronic cough and sputum production. • At this stage, the individual may not be aware that his or her lung function is abnormal. Stage II: Moderate COPD - Worsening airflow limitation (FEV1/FVC < 70%; 50% ≤ FEV1 < 80% predicted), with shortness of breath typically developing on exertion. • This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms or an exacerbation of their disease. Stage III: Severe COPD - Further worsening of airflow limitation (FEV1/FVC < 70%; 30% ≤ FEV1 < 50% predicted), greater shortness of breath, reduced exercise capacity, and repeated exacerbations which have an impact on patients’ quality of life. Stage IV: Very Severe COPD - Severe airflow limitation (FEV1/FVC < 70%; FEV1 < 30% predicted) or FEV1 < 50% predicted plus chronic respiratory failure. Patients may have Very Severe (Stage IV) COPD even if the FEV1 is > 30% predicted, whenever this complication is present. • At this stage, quality of life is very appreciably impaired and exacerbations may be life-threatening. 10 “At Risk for COPD” A major objective of GOLD is to increase awareness among health care providers and the general public of the significance of COPD symptoms. The classification of severity of COPD now includes four stages classified by spirometry—Stage I: Mild COPD; Stage II: Moderate COPD; Stage III: Severe COPD; Stage IV: Very Severe COPD. A fifth category—“Stage 0: At Risk”—that appeared in the 2001 report is no longer included as a stage of COPD, as there is incomplete evidence that the individuals who meet the definition of “At Risk” (chronic cough and sputum production, normal spirometry) necessarily progress on to Stage I: Mild COPD. Nevertheless, the importance of the public health message that chronic cough and sputum are not normal is unchanged and their presence should trigger a search for underlying cause(s). POCKET_GUIDE_06 1/8/07 1:53 PM Page 10 Differential Diagnosis: A major differential diagnosis is asthma. In some patients with chronic asthma, a clear distinction from COPD is not possible using current imaging and physiological testing techniques. In these patients, current management is similar to that of asthma. Other potential diagnoses are usually easier to distinguish from COPD (Figure 3). 11 Diagnosis Suggestive Features* COPD Onset in mid-life. Symptoms slowly progressive. Long smoking history. Dyspnea during exercise. Largely irreversible airflow limitation. Asthma Onset early in life (often childhood). Symptoms vary from day to day. Symptoms at night/early morning. Allergy, rhinitis, and/or eczema also present. Family history of asthma. Largely reversible airflow limitation. Congestive Heart Failure Fine basilar crackles on auscultation. Chest X-ray shows dilated heart, pulmonary edema. Pulmonary function tests indicate volume restriction, not airflow limitation. Bronchiectasis Large volumes of purulent sputum. Commonly associated with bacterial infection. Coarse crackles/clubbing on auscultation. Chest X-ray/CT shows bronchial dilation, bronchial wall thickening. Tuberculosis Onset all ages. Chest X-ray shows lung infiltrate or nodular lesions. Microbiological confirmation. High local prevalence of tuberculosis. Obliterative Bronchiolitis Onset in younger age, nonsmokers. May have history of rheumatoid arthritis or fume exposure. CT on expiration shows hypodense areas. Diffuse Panbronchiolitis Most patients are male and nonsmokers. Almost all have chronic sinusitis. Chest X-ray and HRCT show diffuse small centrilobular nodular opacities and hyperinflation. Figure 3: Differential Diagnosis of COPD *These features tend to be characteristic of the respective diseases, but do not occur in every case. For example, a person who has never smoked may develop COPD (especially in the developing world, where other risk factors may be more important than cigarette smoking); asthma may develop in adult and even elderly patients. POCKET_GUIDE_06 1/8/07 1:53 PM Page 11 12 COMPONENTS OF CARE: A COPD MANAGEMENT PROGRAM The goals of COPD management include: • Relieve symptoms • Prevent disease progression • Improve exercise tolerance • Improve health status • Prevent and treat complications • Prevent and treat exacerbations • Reduce mortality • Prevent or minimize side effects from treatment. Cessation of cigarette smoking should be included as a goal throughout the management program. THESE GOALS CAN BE ACHIEVED THROUGH IMPLEMENTATION OF A COPD MANAGEMENT PROGRAM WITH FOUR COMPONENTS: 1. Assess and Monitor Disease 2. Reduce Risk Factors 3. Manage Stable COPD 4. Manage Exacerbations POCKET_GUIDE_06 1/8/07 1:53 PM Page 12 13 Component 1: Assess and Monitor Disease A detailed medical history of a new patient known or thought to have COPD should assess: • Exposure to risk factors, including intensity and duration. • Past medical history, including asthma, allergy, sinusitis or nasal polyps, respiratory infections in childhood, and other respiratory diseases. • Family history of COPD or other chronic respiratory disease. • Pattern of symptom development. • History of exacerbations or previous hospitalizations for respiratory disorder. • Presence of comorbidities, such as heart disease, malignancies, osteoporosis, and musculoskeletal disorders, which may also contribute to restriction of activity. • Appropriateness of current medical treatments. • Impact of disease on patient’s life, including limitation of activity; missed work and economic impact; effect on family routines; and feelings of depression or anxiety. • Social and family support available to the patient. • Possibilities for reducing risk factors, especially smoking cessation. POCKET_GUIDE_06 1/8/07 1:53 PM Page 13 14 In addition to spirometry, the following other tests should be under- taken for the assessment of a patient with Moderate (Stage II), Severe (Stage III), and Very Severe (Stage IV) COPD. • Bronchodilator reversibility testing: To rule out a diagnosis of asthma, particularly in patients with an atypical history (e.g., asthma in childhood and regular night waking with cough and wheeze). • Chest X-ray: Seldom diagnostic in COPD but valuable to exclude alternative diagnoses such as pulmonary tuberculosis, and identify comorbidities such as cardiac failure. • Arterial blood gas measurement: Perform in patients with FEV1 < 50% predicted or with clinical signs suggestive of respiratory failure or right heart failure. The major clinical sign of respiratory failure is cyanosis. Clinical signs of right heart failure include ankle edema and an increase in the jugular venous pressure. Respiratory failure is indicated by PaO2 < 8.0 kPa (60 mm Hg), with or without PaCO2 > 6.7 kPa (50 mm Hg) while breathing air at sea level. • Alpha-1 antitrypsin deficiency screening: Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of COPD. COPD is usually a progressive disease. Lung function can be expected to worsen over time, even with the best available care. Symptoms and lung function should be monitored to follow the development of complications, to guide treatment, and to facilitate discussion of management options with patients. Comorbidities are common in COPD and should be actively identified. POCKET_GUIDE_06 1/8/07 1:53 PM Page 14 15 Component 2: Reduce Risk Factors Smoking cessation is the single most effective—and