Пулмология

At-A-Glance Outpatient
Management Reference
for Chronic Obstructive
Pulmonary Disease (COPD)
At-A-Glance Outpatient
Management Reference
for Chronic Obstructive
Pulmonary Disease (COPD)
BASED ON THE GLOBAL STRATEGY FOR DIAGNOSIS,
MANAGEMENT AND PREVENTION OF COPD
GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD)
UPDATED 2016
Please refer to the GOLD Report (updated 2016) at www.goldcopd.orgCOPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE

DIAGNOSING COPD
A diagnosis of COPD should be considered in any individual who has
dyspnea, chronic cough or sputum production, and a history of exposure
to risk factors for the disease, especially cigarette smoking.
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
increases the probability of a diagnosis of COPD. Spirometry is
required to establish a diagnosis of COPD.
Dyspnea
that is: Progressive (worsens over time).
Characteristically worse with exercise.
Persistent.

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).
Smoke from home cooking and heating fuels.
Occupational dusts and chemicals.
Family history of COPD
Table 1. Key Indicators for Considering a Diagnosis of COPD
Spirometry is required to make a clinical diagnosis of COPD; the presence of
a postbronchodilator FEV
1
/FVC < 0.70 confirms the presence of persistent
airflow limitation and thus of COPD. All health care workers who care for
COPD patients should have access to spirometry.COPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE

ASSESSMENT OF COPD
The goals of COPD assessment are to determine the severity of the disease, its
impact on patient’s health status, and the risk of future events (exacerbations,
hospital admissions, death) in order to guide therapy. Assess the following
aspects of the disease separately:
• Symptoms
• Degree of airflow limitation (using spirometry)
• Risk of exacerbations
• Comorbidities
Assess Symptoms: Validated questionnaires such as the COPD Assessment
Test (CAT) or the Clinical COPD Questionnaire (CCQ) are recommended
for a comprehensive assessment of symptoms. The modified British
Medical Research Council (mMRC) scale provides only an assessment of
breathlessness.
Assess Degree of Airflow Limitation Using Spirometry: Table 2 provides the
classification of airflow limitation severity in COPD.
Assess Risk of Exacerbations: An exacerbation of COPD is defined as an acute
event characterized by a worsening of the patient’s respiratory symptoms that
is beyond normal day-to-day variations and leads to a change in medication.
The best predictor of having frequent exacerbations (2 or more per year) is
a history of previous treated events; the risk of exacerbations also increases
as airflow limitation worsens. Hospitalization for a COPD exacerbation is
associated with a poor prognosis with increased risk of death.
Table 2. Classification of Severity of Airflow Limitation in COPD
(Based on Post-Bronchodilator FEV
1
)
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV
1
≥ 80% predicted
GOLD 2: Moderate 50% ≤ FEV
1
< 80% predicted
GOLD 3: Severe 30% ≤ FEV
1
< 50% predicted
GOLD 4: Very Severe FEV
1
< 30% predictedCOPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE

Assess Comorbidities: Cardiovascular diseases, osteoporosis, depression
and anxiety, skeletal muscle dysfunction, metabolic syndrome, and lung
cancer among other diseases occur frequently in COPD patients. These
comorbid conditions may influence mortality and hospitalizations, and
should be looked for routinely and treated appropriately.
Combined Assessement of COPD: Table 3 provides a rubric for combining
these assessments to improve management of COPD.
• Symptoms:
Less Symptoms (mMRC 0-1 or CAT < 10): patient is (A) or (C)
More Symptoms (mMRC ≥ 2 or CAT ≥ 10): patient is (B) or (D)
• Airflow Limitation: L
ow Risk (GOLD 1 or 2): patient is (A) or (B)
High Risk (GOLD 3 or 4): patient is (C) or (D)
• Exacerbations:
Low Risk: ≤ 1 per year and no hospitalization for exacerbation: patient is (A) or (B)
High Risk: ≥ 2 per year or ≥ 1 with hospitalization: patient is (C) or (D)
Table 3. 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.)
Patient Characteristic
Spirometric
Classification
Exacerbations per yearCAT mMRC
A
Low Risk
Less Symptoms
GOLD 1-2 ≤ 1 < 10 0-1
B
Low Risk
More Symptoms
GOLD 1-2 ≤ 1 ≥ 10 ≥ 2
C
High Risk
Less Symptoms
GOLD 3-4 ≥ 2 < 10 0-1
D
High Risk
More Symptoms
GOLD 3-4 ≥ 2 ≥ 10 ≥ 2
(C) (D)
(A) (B)
Risk
(Exacrbation History)
Risk
(Gold Classification of Airflow Limitation )
Symptoms
Breathlessness
CAT < 10 CAT ≥ 10
mMRC 0-1 mMRC ≥ 2
≥ 2
or
≥1 leading
to hospital
admission
1 (not leading
to hospital
admission)
0COPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE

Once COPD has been diagnosed, effective management should be based on an
individualized assessment of current symptoms and future risks:
• Relieve symptoms
• Improve exercise tolerance
• Improve health status
and
• Prevent disease progression
• Prevent and treat exacerbations
• Reduce mortality
These goals should be reached with minimal side effects from treatment, a particular
challenge in COPD patients because they commonly have comorbidities that also
need to be carefully identified and treated.
Bronchodilators – Recommendations:
• For both beta
2
-agonists and anticholinergics, long-acting formulations are
preferred over short-acting formulations.
• The combined use of short- or long-acting beta
2
-agonists and anticholinergics
may be considered if symptoms are not improved with single agents.
• Based on efficacy and side effects, inhaled bronchodilators are preferred
over oral bronchodilators.
• Based on evidence of relatively low efficacy and greater side effects,
treatment with theophylline is not recommended unless other bronchodilators
are not available or unaffordable for long-term treatment.
Corticosteroids and Phosphodiesterase-4 Inhibitors – Recommendations
• There is no evidence to recommend a short-term therapeutic trial with oral
corticosteroids in patients with COPD to identify those who will respond to
inhaled corticosteroids or other medications.
• Long-term treatment with inhaled corticosteroids is recommended for
patients with severe and very severe airflow limitation and for patients with
frequent exacerbations that are not adequately controlled by long-acting
bronchodilators.
• Long-term monotherapy with oral corticosteroids is not recommended in
COPD.
• Long-term monotherapy with inhaled corticosteroids is not recommended
in COPD because it is less effective than the combination of inhaled
corticosteroids with long-acting beta2-agonists.
• Long-term treatment containing inhaled corticosteroids should not be
prescribed outside their indications, due to the risk of pneumonia and the
possibility of a slightly increased risk of fractures following long-term-term
exposure.
• The phosphodiesterase-4 inhibitor roflumilast may also be used to reduce
exacerbations for patients with chronic bronchitis, severe and very severe
airflow limitation, and frequent exacerbations that are not adequately
controlled by long-acting bronchodilators.
MANAGEMENT OF STABLE COPD
REDUCE SYMPTOMS
REDUCE RISKCOPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE

*Medications in each
box are mentioned
in alphabetical order
and therefore not
necessarily in order
of preference.
**Medications in
this column can be
used alone or in
combination with
other options in the
First and Alternative
Choice columns
Glossary:
SA: short-acting
LA: long-acting
ICS: inhaled
corticosteroid
PDE-4:
phosphodiesterase-4
prn: when necessary
Table 4: Pharmacologic Therapy for Stable COPD*
Patient
Group
RECOMMENDED
FIRST CHOICE
ALTERNATIVE CHOICEOTHER POSSIBLE TREATMENTS**
A
SA anticholinergic prn
or
SA beta
2
-agonist prn
LA anticholinergic
or
LA beta
2
-agonist
or
SA beta
2
-agonist and
SA anticholinergic
Theophylline
B
LA anticholinergic
or
LA beta
2
-agonist
LA anticholinergic and
LA beta
2
-agonist
SA beta
2
-agonist and/or
SA anticholinergic
Theophylline
C
ICS + LA beta
2
-agonist
or
LA anticholinergic
LA anticholinergic and
LA beta
2
-agonist
or
LA anticholinergic and
PDE-4 Inhibitor
or
LA beta
2
-agonist and
PDE-4 Inhibitor
SA beta
2
-agonist and/or
SA anticholinergic
Theophylline
D
ICS + LA beta
2
-agonist
and/or
LA anticholinergic
ICS + LA beta
2
-agonist and
LA anticholinergic
or
ICS + LA beta
2
-agonist and
PDE-4 inhibitor
or
LA anticholinergic and
LA beta
2
-agonist
or
LA anticholinergic and
PDE-4 inhibitor
Carbocysteine
N-acetylcysteine
SA beta
2
-agonist and/or
SA anticholinergic
TheophyllineCOPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE

Table 5. Formulations and Typical Doses of COPD Medications*
Drug Inhaler (µg)
Solution for
Nebulizer
(mg/ml)
Oral
Vials for
Injection
(mg)
Duration of
Action (hours)
Beta
2
-agonists - Short-acting
Fenoterol 100-200 (MDI) 1 0.05% (Syrup) 4-6
Levalbuterol 45-90 (MDI)0.21, 0.42 6-8
Salbutamol (albuterol)100, 200 (MDI & DPI)5
5 mg (Pill),
0.024%(Syrup)
0.1, 0.54-6
Terbutaline 400, 500 (DPI) 2.5, 5 mg (Pill) 4-6
Beta
2
-agonists - Long-acting
Formoterol 4.5-12 (MDI & DPI)0.01
¶
12
Arformoterol 0.0075 12
Indacaterol 75-300 (DPI) 24
Olodaterol 5mcg (SMI) 24
Salmeterol 25-50 (MDI & DPI) 12
Tulobuterol 2 mg (transdermal) 24
Anticholinergics - Short-acting
Ipratropium bromide20, 40 (MDI)0.25-0.5 6-8
Oxitropium bromide 100 (MDI) 1.5 7-9
Anticholinergics - Long-acting
Aclidinium bromide322 (DPI) 12
Glycopyrronium bromide44 (DPI) 24
Tiotropium 18 (DPI), 5 (SMI) 24
Umeclidinium 62.5 (DPI) 24
Combination short-acting beta
2
-agonists plus anticholinergic in one inhaler
Fenoterol/Ipratropium200/80 (MDI)1.25/0.5 6-8
Salbutamol/Ipratropium100/20 (SMI) 6-8
Combination long-acting beta
2
-agonist plus anticholinergic in one inhaler
Formoterol/aclidinium 12/340 (DPI) 12
Indacaterol/glycopyrronium85/43 (DPI) 24
Olodaterol/tiotropium5/5 (SMI) 24
Vilanterol/umeclidinium25/62.5 (DPI) 24
Methylxanthines
Aminophylline 200-600 mg (Pill)240Variable, up to 24
Theophylline (SR) 100-600 mg (Pill)Variable, up to 24
Inhaled corticosteroids
Beclomethasone50-400 (MDI & DPI)0.2-0.4
Budesonide 100, 200, 400 (DPI)
0.20. 0.25,
0.5
Fluticasone 50-500 (MDI & DPI)
Combination long-acting beta
2
-agonists plus corticosteroids in one inhaler
Formoterol/beclometasone6/100 (MDI & DPI)
Formoterol/budesonide
4.5/160 (MDI)
9/320 (DPI)
Formoterol/mometasone10/200, 10/400 (MDI)
Salmeterol/Fluticasone50/100, 250, 500 (DPI)
Vilanterol/Fluticasone
furoate
25/100 (DPI)
Systemic corticosteroids
Prednisone 5-60 mg (Pill)
Methyl-prednisolone 4, 8, 16 mg (Pill)
Phosphodiesterase-4 inhibitors
Roflumilast 500 mcg (Pill) 24
MDI=metered dose inhaler; DPI=dry powder inhaler; SMI=soft mist inhaler
*Not all formulations are available in all countries; in some countries, other formulations may be available.
¶Formoterol nebulized solution is based on the unit dose vial containing 20 mcg in a volume of 2.0 mlCOPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE

GOLD 2016 source documents are at www.goldcopd.org
© Global Initiative for Chronic Obstructive Lung DiseaseCOPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE