Update on heterogeneity of COPD, evaluation of COPD ...

copy 2014 Global Initiative for Chronic Obstructive Lung Disease

Update on heterogeneity of COPD evaluation of COPD severity and

exacerbation

Yung-Yang Liu MD Taipei Veterans General Hospital

Aug 29 2015

lobal Initiative for Chronic

bstructive

ung

isease

G

O

L

D


Evidence

Category

Sources of Evidence

A Randomized controlled trials

(RCTs) Rich body of data

B Randomized controlled trials

(RCTs) Limited body of data

C Nonrandomized trials

Observational studies

D Panel consensus judgment

Description of Levels of Evidence


Global Strategy for Diagnosis Management and Prevention of COPD

Definition of COPD

COPD a common preventable and treatable disease is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases

Exacerbations and comorbidities contribute to the overall severity in individual patients



Mechanisms Underlying Airflow Limitation in COPD

Small Airways Disease

bull Airway inflammation bull Airway fibrosis luminal plugs bull Increased airway resistance

Parenchymal Destruction

bull Loss of alveolar attachments bull Decrease of elastic recoil

AIRFLOW LIMITATION copy 2014 Global Initiative for Chronic Obstructive Lung Disease


Heterogeneity of COPD

- Genetic Phenotypes - Although smoking is the major risk factor for the development of COPD the development of airflow obstruction in smokers is highly variable Severe 1 antitrypsin deficiency is a proven genetic risk factor for COPD - Familial aggregation of airflow obstruction within families of COPD patients has also been demonstrated - A recent association study comprising 8300 patients and 7 separate cohorts found that a minor allele SNP of MMP12 (rs2276109) associated with decreased MMP-12 expression has a positive effect on lung function in children with asthma and in adult smokers - Recent genome-wide association studies have identified several COPD loci including a region near the hedgehog interacting protein (HHIP) gene on chromosome 4 and a cluster of genes on chromosome 15 that likely contain COPD susceptibility determinants

- Barreiro E Update in Chronic Obstructive Pulmonary Disease 2013

Am J Respir Crit Care Med 20141891337-44



- Allergy Phenotypes

- In the National Health and Nutrition Survey III

(NHANES III) individuals with an allergic phenotype were more likely to wheeze and have chronic cough and phlegm and increased risk of exacerbations - In the COPD and Domestic Endotoxin (CODE) cohort sensitized subjects reported more wheeze cough-induced nocturnal awakenings and exacerbations and acute health visits - Active allergic symptoms may worsen the course of COPD - Allergen avoidance or pharmacologic treatment of allergic disease is warranted in specific subjects with COPD






Heterogeneity of COPD - Clinical Phenotypes

COPD clinical phenotypes



- Soriano JB Chest 2003124(2)474-481

bull Non-proportional Venn diagram of COPD showing subsets of patients with chronic bronchitis emphysema and asthma The subsets comprising COPD are shaded Patients with asthma whose airflow obstruction is completely reversible (9) are not considered to have COPD Patients with unremitting asthma are classified as having COPD (6 7 and 8) Chronic bronchitis and emphysema with airflow obstruction usually occur together (5) and some patients may have asthma associated with these two disorders (8)

- Clinical Phenotypes



- Soriano JB Chest 2003124(2)474-481

bull Those with asthma exposed to cigarette smoke may develop chronic productive cough which is a feature of chronic bronchitis (6) Such patients often are referred as having asthmatic bronchitis or the asthmatic form of COPD Persons with chronic bronchitis andor emphysema without airflow obstruction (1 2 and 11) are not classified as having COPD Patients with airway obstruction due to diseases with other specific pathology eg cystic fibrosis or obliterative bronchiolitis (10) are not included in this definition


Type 1

Type 2

Type 3

E 432

CB 447

COPD-asthma 121



FEV1 (forced expiratory volume in 1 sec) is the

hallmark of COPD because it is affected by inflammation and remodeling of the small airways as well as by emphysematous destruction of the terminal airspaces however defining a disease as COPD so heterogeneous exclusively based on the patientrsquos FEV1 may not always be adequate

- Coxson HO Using Pulmonary Imaging to Move COPD Beyond FEV1

Am J Respir Crit Care Med 2014 May 29



bull COPD is a diverse disease with many clinical radiological and genomic features that may designate several different phenotypes that may have prognostic as well as therapeutic implications

bull Chest CT uses lung structure to characterize the COPD population into emphysema or airway-predominant phenotypes that may provide keen insight into disease progression and response to therapy




Heterogeneity of COPD Radiological phenotypes Emphysema-predominant and airway-predominant

E A M

- Pistolesi M Identification of a predominant COPD phenotype in clinical practice

Respir Med 2008102(3)367-76





- Kitaguchi Y Characteristics of COPD phenotypes classified according to the findings of HRCT

Respir Med 2006100(10)1742-52

- Stable moderate-to-severe COPD patients

ldquoArdquo absence or with little emphysema but with or without bronchial wall thickening (BWT) ldquoErdquo emphysema without BWT ldquoMrdquo mixed type emphysema with BWT




Respir Med 2006100(10)1742-52







bull The ldquoArdquo type showed a higher prevalence of non-smoker and patients with wheezing both on exertion and at rest higher values of DLCO milder lung hyperinflation and greater reversibility of airflow obstruction responsive to inhaled 2-agonist as compared with the ldquoErdquo phenotype

bull The ldquoErdquo type showed a significantly lower preference of BMI declined DLCO and poor response to inhaled 2-agnoist among three groups

bull The ldquoMrdquo type showed a higher prevalence of patients complaining of large amounts of sputum productive cough and wheezing not only on exertion but also at rest higher rate of acute exacerbation or hospitalization and greater reversibility of airflow obstruction responsive to inhaled 2-agnoist as compared with the ldquoErdquo phenotype


Respir Med 2006100(10)1742-52



bull The degree of emphysema was significantly associated with Brinkman (smoking) index lower BMI a decrease in DLCO lower FEV1FVC values

bull The presence of bronchial wall thickening in ldquoArdquo- and ldquoMrdquo- phenotype was significantly associated with reversibility responsive to treatment with inhaled corticosteroid and sputum eosinophilia

bull These findings indicated that the morphological phenotypes of COPD classified according to dominancy of emphysema and the presence of BWT showed several clinical characteristics and different bronchodilator responses


Respir Med 2006100(10)1742-52



- Bafadhel M The role of CT scanning in multidimensional phenotyping of COPD

Chest 2011140(3)634-42

bull COPD with E - More severe PFT darr

- More airway inflammation - Serious systemic dysfunction

bull COPD with BE - Probable pathogenic bacterial culture uarr - AEyear uarr - Mortality uarr

bull COPD with BWT - Correlate with reversibility to BD

Global Strategy for Diagnosis Management and Prevention of COPD 2014 Chapters

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014



Diagnosis and Assessment Key Points

A clinical diagnosis of COPD should be considered in any patient who has dyspnea chronic cough or sputum production and a history of exposure to risk factors for the disease

Spirometry is required to make the diagnosis the presence of a post-bronchodilator FEV1FVC lt 070 confirms the presence of persistent airflow limitation and thus of COPD




The goals of COPD assessment are to determine the severity of the disease including (1) the severity of airflow limitation (2) the impact on the patientrsquos health status and (3) the risk of future exacerbations in order to guide therapy

The risk of future exacerbations estimated by the severity of airflow limitation and the history of previous exacerbations

Comorbidities occur frequently in COPD patients and should be actively looked for and treated appropriately if present


SYMPTOMS

chronic cough

shortness of breath

EXPOSURE TO RISK FACTORS

tobacco

occupation

indooroutdoor pollution

SPIROMETRY Required to establish diagnosis


Diagnosis of COPD

sputum



Assessment of Airflow Limitation Spirometry

Spirometry should be performed after the administration of an adequate dose of a short- acting inhaled bronchodilator to minimize variability

A post-bronchodilator FEV1FVC lt 070 confirms the presence of airflow limitation

Where possible values should be compared to age-related normal values to avoid overdiagnosis of COPD in the elderly


Spirometry Normal Trace Showing FEV1 and FVC

1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08


Spirometry Obstructive Disease Volu

me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive


Determine the severity of the disease its impact on the patientrsquos health status and the risk of future events (for example exacerbations) to guide therapy Consider the following aspects of the disease separately

current level of patientrsquos symptoms severity of the spirometric abnormality frequency of exacerbations presence of comorbidities


Assessment of COPD Goals


S-S-E-C


Assessment of COPD

Assess symptoms

Assess degree of airflow limitation using spirometry

Assess risk of exacerbations

Assess comorbidities copy 2014 Global Initiative for Chronic Obstructive Lung Disease

The characteristic symptoms of COPD are chronic and progressive dyspnea cough and sputum production that can be variable from day-to-day

Dyspnea Progressive persistent and characteristically worse with exercise

Chronic cough May be intermittent and may be unproductive

Chronic sputum production COPD patients commonly cough up sputum


Symptoms of COPD


Assess symptoms Assess degree of airflow limitation using

spirometry


Assess comorbidities

COPD Assessment Test (CAT)

or

Clinical COPD Questionnaire (CCQ)

or

mMRC Breathlessness scale


Assessment of COPD


COPD Assessment Test (CAT) An 8-item measure of health status impairment in COPD (httpcatestonlineorg) Clinical COPD Questionnaire (CCQ) Self-administered questionnaire developed to measure clinical control in patients with COPD (httpwwwccqnl)


Assessment of Symptoms


The equivalent cut-

point for the CAT is

10

CCQ questionnaire Calculation of scores CCQ total score = (item 1 + 2 + 3 + 4 + 5 + 6 + 7 + 8 + 9 + 10)10 Symptom = (item 1 + 2 + 5 + 6)4 Functional state = (item 7 + 8 + 9 + 10)4 Mental state = (item 3 + 4)2

The equivalent cut-point for the CCQ is

10 ndash 15

Breathlessness Measurement using the Modified British Medical Research Council (mMRC) Questionnaire - relates well to other measures of health status and predicts future mortality risk





Modified MRC (mMRC) Questionnaire


Less

breathlessness

More

breathlessness

Assess symptoms




Use spirometry for grading severity according to spirometry using four grades split at 80 50 and 30

of predicted value


Assessment of COPD



Classification of Severity of Airflow Limitation in COPD

In patients with FEV1FVC lt 070 GOLD 1 Mild FEV1 gt 80 predicted GOLD 2 Moderate 50 lt FEV1 lt 80 predicted GOLD 3 Severe 30 lt FEV1 lt 50 predicted GOLD 4 Very Severe FEV1 lt 30 predicted Based on Post-Bronchodilator FEV1 copy 2014 Global Initiative for Chronic Obstructive Lung Disease

- Jones PW Health status and the spiral of decline COPD 20096(1)59-63

Assess symptoms




An exacerbation of COPD is defined as an acute event

characterized by a worsening of the patientrsquos respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication


Assessment of COPD



Assess Risk of Exacerbations

To assess risk of exacerbations use history of exacerbations and spirometry

Two or more exacerbations within the last year or an FEV1 lt 50 of predicted value are indicators of high risk

One or more hospitalizations for COPD exacerbation should be considered high risk


bull Exacerbations increase the decline in lung function deterioration in health status and risk of death the assessment of exacerbation risk can also be seen as an assessment of the risk of poor outcomes in general


Combined Assessment of COPD

Assess symptoms



Combine these assessments for the purpose of improving management of COPD





Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)

ge 2 or gt 1 leading to hospital admission 1 (not leading to hospital admission) 0

Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10

Breathlessness mMRC 0ndash1 mMRC gt 2



(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms

If CAT lt 10 or mMRC 0-1 Less Symptomsbreathlessness

(A or C)

If CAT gt 10 or mMRC gt 2 More Symptomsbreathlessness

(B or D)

Assess symptoms first

copy 2014 Global Initiative for Chronic Obstructive Lung Disease Breathlessness

mMRC 0ndash1 mMRC gt 2


Combined Assessment of COPD R

isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms

If GOLD 3 or 4 or ge 2 exacerbations per year or

gt 1 leading to hospital admission

High Risk (C or D)

If GOLD 1 or 2 and only 0 or 1 exacerbations per

year (not leading to hospital admission)

Low Risk (A or B)

Assess risk of exacerbations next







Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10


When assessing risk choose the highest risk according to GOLD spirometric grade or exacerbation history history

Patient Characteristic Spirometric

Classification

Exacerbations

per year

CAT mMRC

A Low Risk

Less Symptoms GOLD 1-2 le 1 lt 10 0-1

B Low Risk

More Symptoms GOLD 1-2 le 1 gt 10 gt 2

C High Risk

Less Symptoms GOLD 3-4 gt 2 lt 10 0-1

D High Risk

More Symptoms GOLD 3-4 gt 2 gt 10

gt 2


Combined Assessment of COPD When assessing risk choose the highest risk according to GOLD grade or exacerbation history (One or more hospitalizations for COPD exacerbations should be considered high risk)


Manage Stable COPD Pharmacologic Therapy (Medications in each box are mentioned in alphabetical order and

therefore not necessarily in order of preference)

Patient Recommended

First Choice

Alternative Choice Other Possible

Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA

LAMA and LABA SABA andor SAMA

Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or

LAMA and PDE4-inh or

LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA

ICS + LABA and LAMA or

ICS+LABA and PDE4-inh or

LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline

Patients with symptoms disproportionate to the severity of obstruction (subgroup B) may be at higher risk of death

Evidence to support this classification system

bull Patients with a high risk of exacerbations tend to be in GOLD categories 3 and 4 (Severe or Very Severe airflow limitation) and can be identified quite reliably from the their own past history bull Higher exacerbation rates are associated with faster loss of FEV1 and greater worsening of health status bull Hospitalization for a COPD exacerbation is associated with poor prognosis bull CAT score ≧ 10 are associated with significantly

impaired health status


Assess COPD Comorbidities

COPD patients are at increased risk for

bull Cardiovascular diseases bull Osteoporosis skeletal muscle dysfunction bull Respiratory infections bull Anxiety and Depression bull Diabetes metabolic syndrome bull Lung cancer bull Bronchiectasis

These comorbid conditions may influence mortality and

hospitalizations and should be looked for routinely and

treated appropriately copy 2014 Global Initiative for Chronic Obstructive Lung Disease


Differential Diagnosis COPD and Asthma

COPD

bull Onset in mid-life

bull Symptoms slowly progressive

bull Long smoking history

ASTHMA

bull Onset early in life (often childhood)

bull Symptoms vary from day to day

bull Symptoms worse at nightearly morning

bull Allergy rhinitis andor eczema also present

bull Family history of asthma



Additional Investigations

Imaging Chest X-ray Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities Computed tomography (CT) of the chest Might help in DD when concomitant diseases exist

Lung Volumes and Diffusing Capacity Help to characterize severity but not essential to patient management

Oximetry and Arterial Blood Gases Pulse oximetry can be used to evaluate a patientrsquos oxygen saturation and need for supplemental oxygen therapy

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


Exercise Testing Objectively measured exercise impairment assessed by a reduction in self-paced walking distance (such as the 6 min walking test) or during incremental exercise testing in a laboratory is a powerful indicator of health status impairment and predictor of prognosis

Composite Scores Several variables (FEV1 exercise tolerance assessed by walking distance or peak oxygen consumption weight loss and reduction in the arterial oxygen tension) identify patients at increased risk for mortality The BODE (BMI Obstruction Dyspnea and Exercise) index is a better predictor of subsequent survival




Impact on Symptoms and Lung Function

Negative Impact on

Quality of Life

Consequences Of COPD Exacerbations

Increased Socioeconomic

Costs

Accelerated Lung Function

Decline

Increased Mortality

EXACERBATIONS


Arterial blood gas measurements (in hospital) PaO2 lt 60 mmHg with or without PaCO2 gt 50 mmHg when breathing room air indicates respiratory failure

Chest radiograph useful to exclude alternative diagnoses

ECG may aid in the diagnosis of coexisting cardiac problems

Whole blood count identify polycythemia anemia or bleeding

Purulent sputum during an exacerbation indication to begin empirical antibiotic treatment

Biochemical tests detect electrolyte disturbances diabetes and poor nutrition

Spirometric tests not recommended during an exacerbation


Manage Exacerbations Assessments





The best predictor of exacerbations is a history of exacerbations




Oxygen titrate to improve the patientrsquos hypoxemia with a

target saturation of 88-92

Bronchodilators Short-acting inhaled beta2-agonists with or

without short-acting anticholinergics are preferred

Systemic Corticosteroids Shorten recovery time improve

lung function (FEV1) and arterial hypoxemia (PaO2) and

reduce the risk of early relapse treatment failure and length

of hospital stay A dose of 40 mg prednisone per day for 5

days is recommended


Manage Exacerbations Treatment Options


Antibiotics should be given to patients with Three cardinal symptoms increased

dyspnea increased sputum volume and increased sputum purulence

Who require mechanical ventilation




Marked increase in intensity of symptoms

Severe underlying COPD

Onset of new physical signs

Failure of an exacerbation to respond to initial medical management

Presence of serious comorbidities

Frequent exacerbations

Older age

Insufficient home support


Manage Exacerbations Indications for

Hospital Admission


Thanks for your attention

lobal Initiative for Chronic

bstructive

ung

isease

G

O

L

D


Evidence

Category

Sources of Evidence











Definition of COPD






























- Soriano JB Chest 2003124(2)474-481





- Soriano JB Chest 2003124(2)474-481



Type 1

Type 2

Type 3

E 432

CB 447

COPD-asthma 121















E A M


Respir Med 2008102(3)367-76






Respir Med 2006100(10)1742-52






Respir Med 2006100(10)1742-52











Respir Med 2006100(10)1742-52







Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission



Evidence

Category

Sources of Evidence











Definition of COPD






























- Soriano JB Chest 2003124(2)474-481





- Soriano JB Chest 2003124(2)474-481



Type 1

Type 2

Type 3

E 432

CB 447

COPD-asthma 121















E A M


Respir Med 2008102(3)367-76






Respir Med 2006100(10)1742-52






Respir Med 2006100(10)1742-52











Respir Med 2006100(10)1742-52







Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission




Definition of COPD






























- Soriano JB Chest 2003124(2)474-481





- Soriano JB Chest 2003124(2)474-481



Type 1

Type 2

Type 3

E 432

CB 447

COPD-asthma 121















E A M


Respir Med 2008102(3)367-76






Respir Med 2006100(10)1742-52






Respir Med 2006100(10)1742-52











Respir Med 2006100(10)1742-52







Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission





























- Soriano JB Chest 2003124(2)474-481





- Soriano JB Chest 2003124(2)474-481



Type 1

Type 2

Type 3

E 432

CB 447

COPD-asthma 121















E A M


Respir Med 2008102(3)367-76






Respir Med 2006100(10)1742-52






Respir Med 2006100(10)1742-52











Respir Med 2006100(10)1742-52







Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission





- Soriano JB Chest 2003124(2)474-481



Type 1

Type 2

Type 3

E 432

CB 447

COPD-asthma 121















E A M


Respir Med 2008102(3)367-76






Respir Med 2006100(10)1742-52






Respir Med 2006100(10)1742-52











Respir Med 2006100(10)1742-52







Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission



Type 1

Type 2

Type 3

E 432

CB 447

COPD-asthma 121















E A M


Respir Med 2008102(3)367-76






Respir Med 2006100(10)1742-52






Respir Med 2006100(10)1742-52











Respir Med 2006100(10)1742-52







Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission

















E A M


Respir Med 2008102(3)367-76






Respir Med 2006100(10)1742-52






Respir Med 2006100(10)1742-52











Respir Med 2006100(10)1742-52







Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission








Respir Med 2006100(10)1742-52






Respir Med 2006100(10)1742-52











Respir Med 2006100(10)1742-52







Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission






Respir Med 2006100(10)1742-52











Respir Med 2006100(10)1742-52







Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission













Respir Med 2006100(10)1742-52







Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission









Respir Med 2006100(10)1742-52




Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission






Chest 2011140(3)634-42








Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission






Therapeutic Options

Manage Stable COPD



Asthma COPD Overlap

Syndrome (ACOS)

Updated 2014













SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission














SYMPTOMS

chronic cough

shortness of breath


tobacco

occupation




Diagnosis of COPD

sputum









1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission










1 2 3 4 5 6

1

2

3

4

Volu

me lit

ers

Time sec

FVC 5

1

FEV1 = 4L

FVC = 5L

FEV1FVC = 08



me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission




me lit

ers

Time seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 18L

FVC = 32L

FEV1FVC = 056

Normal

Obstructive







S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission








S-S-E-C


Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission




Assessment of COPD

Assess symptoms









Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission








Symptoms of COPD



spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission




spirometry




or


or



Assessment of COPD






The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission







The equivalent cut-


10



10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission





10 ndash 15








Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission










Less

breathlessness

More

breathlessness

Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission



Assess symptoms





of predicted value


Assessment of COPD






Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission







Assess symptoms







Assessment of COPD











Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission












Assess symptoms








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission






Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission





(C) (D)

(A) (B)

CAT lt 10 CAT gt 10

Symptoms


(A or C)


(B or D)






isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission





isk

(GO

LD

Cla

ssific

ation o

f A

irfl

ow

Lim

itati

on

)

Ris

k

(Exacerb

atio

n h

isto

ry)

(C) (D)

(A) (B)

4

3

2

1

CAT lt 10 CAT gt 10

Symptoms



High Risk (C or D)



Low Risk (A or B)








Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission






Ris

k

(GO

LD C

lass

ific

atio

n o

f A

irfl

ow

Lim

itat

ion

))

Ris

k

(Exa

cerb

atio

n h

isto

ry)


Symptoms

(C) (D)

(A) (B)

CAT lt 10

4

3

2

1

CAT gt 10




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission




Classification

Exacerbations

per year

CAT mMRC

A Low Risk


B Low Risk


C High Risk


D High Risk


gt 2






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission






Patient Recommended

First Choice


Treatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA


Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or


LABA and PDE4-inh

SABA andor SAMA

Theophylline

D

ICS + LABA

andor

LAMA



LAMA and LABA or

LAMA and PDE4-inh

Carbocysteine

SABA andor SAMA

Theophylline














COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission
















COPD




ASTHMA




















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission
















Negative Impact on

Quality of Life



Costs


Decline

Increased Mortality

EXACERBATIONS



























days is recommended
















Older age




Hospital Admission




























days is recommended
















Older age




Hospital Admission















Older age




Hospital Admission



Update on heterogeneity of COPD, evaluation of COPD ...

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