Presentación Oficial EPOC GOLD
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Transcript of Presentación Oficial EPOC GOLD
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Global Initiative for Chronic Obstructive Lung Disease
GLOBAL INITIATIVE FOR CHRONIC
OBSTRUCTIVE LUNG DISEASE (GOLD):TEACHING SLIDE SET
January 2013This slide set is restricted for academic and educational
purposes only. Use of the slide set, or of individualslides, for commercial or promotional purposes requiresapproval from GOLD.
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lobal Initiative for Chronic
bstructive
ung
isease
GO
L
D
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GOLD Structure
GOLD Board of Directors
Marc Decramer, MDChair
Science Committee
Jrgen Vestbo, MD - Chair
Dissemination/Implementation
CommitteeJean Bourbeau, MD - Chair
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GOLD Board of Directors: 2013
J. Bourbeau, Canada
B. Celli, U..S.
D. Hui, Hong Kong PRCV. Lopez Varela, Uruguay
M. Nishimura, Japan
R. Rodriguez-Roisin,Spain
R. Stockley, U.K.J. Vestbo, Denmark, U.K.
C. Vogelmeier, Germany
2013 Global Initiative for Chronic Obstructive Lung Disease
M. Decramer,Chair, Belgium
J. Vestbo, Vice Chair, Denmark, U.K
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GOLD Science Committee - 2013
Jrgen Vestbo, MD, Chair
Alvar Agusti, MD
Antonio Anzueto, MD
Peter Barnes, MD
Leonardo Fabbri, MD
Paul Jones, MD
Fernando Martinez, MD
Nicolas Roche, MD
Roberto Rodriguez-Roisin, MD
Don Sin, MD
Robert Stockley, MDClaus Vogelmeier, MD
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EvidenceCategory
Sources of Evidence
A Randomized controlled trials(RCTs). Rich body of data
B Randomized controlled trials(RCTs). Limited body of data
C Nonrandomized trialsObservational studies.
D Panel consensus judgment
Description of Levels of Evidence
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GOLD Structure
GOLD Board of Directors
Marc Decramer, MDChair
Science Committee
Jrgen Vestbo, MD - Chair
Dissemination/Implementation
CommitteeJean Bourbeau, MD - Chair
GOLD National Leaders - GNL 2013 Global Initiative for Chronic Obstructive Lung Disease
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United States
United Kingdom
Argentina
Australia
Brazil
AustriaCanada
Chile
Belgium
China
Denmark
Columbia
Croatia
Egypt
Germany
Greece
Ireland
Italy
SyriaHong Kong ROC
Japan
Iceland
India
Korea
Kyrgyzstan
Uruguay
Moldova
Nepal
Macedonia
Malta
Netherlands
New Zealand
Poland
Norway
Portugal
Georgia
Romania
Russia
SingaporeSlovakia
Slovenia Saudi Arabia
South Afr ica
Spain
Sweden
Thailand
Switzerland
Ukraine
United Arab Emirates
Taiwan ROC
Venezuela
Vietnam
Peru
Yugoslavia
Bangladesh
France
Mexico
Turkey CzechRepublic
Pakistan
Israel
GOLD National Leaders
Philippines
Yeman
Kazakhstan
Mongolia
Albania
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GOLD Website Address
http://www.goldcopd.org
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lobal Initiative for Chronic
bstructive
ung
isease
GO
L
D 2013 Global Initiative for Chronic Obstructive Lung Disease
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GOLD Objectives
Increase awareness of COPD amonghealth professionals, health
authorities, and the general publicImprove diagnosis, management andprevention
Decrease morbidity and mortality
Stimulate research 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage ComorbiditiesUpdated 2013
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Global Strategy for Diagnosis, Management and Prevention of COPD
Definition of COPD
COPD, a common preventable and treatabledisease, is characterized by persistent airflowlimitation that is usually progressive andassociated with an enhanced chronicinflammatory response in the airways and thelung to noxious particles or gases.
Exacerbations and comorbidities contribute tothe overall severity in individual patients.
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Global Strategy for Diagnosis, Management and Prevention of COPD
Mechanisms Underlying
Airflow Limitation in COPD
Small Airways Disease
Airway inflammation Airway fibrosis, luminal plugs Increased airway resistance
Parenchymal Destruction
Loss of alveolar attachments Decrease of elastic recoil
AIRFLOW LIMITATION 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Burden of COPD
COPD is a leading cause of morbidity andmortality worldwide.
The burden of COPD is projected to increasein coming decades due to continuedexposure to COPD risk factors and the aging
of the worlds population.
COPD is associated with significant economicburden.
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Global Strategy for Diagnosis, Management and Prevention of COPD
Risk Factors for COPD
Lung growth and development
Gender
Age
Respiratory infections
Socioeconomic status
Asthma/Bronchial
hyperreactivityChronic Bronchitis
Genes
Exposure to particles
Tobacco smoke
Occupational dusts, organicand inorganic
Indoor air pollution fromheating and cooking with
biomass in poorly ventilateddwellings
Outdoor air pollution
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Global Strategy for Diagnosis, Management and Prevention of COPD
Risk Factors for COPD
Genes
Infections
Socio-economic
status
Aging Populations 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage ComorbiditiesUPDATED 2013
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Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key Points
A clinical diagnosis of COPD should beconsidered in any patient who has dyspnea,chronic cough or sputum production, and a
history of exposure to risk factors for thedisease.
Spirometry is requiredto make the diagnosis;
the presence of a post-bronchodilator FEV1/FVC< 0.70 confirms the presence of persistentairflow limitation and thus of COPD.
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Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key Points
The goals of COPD assessment are to determinethe severity of the disease, including the severity ofairflow limitation, the impact on the patients health
status, and the risk of future events.
Comorbidities occur frequently in COPD patients,and should be actively looked for and treated
appropriately if present.
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SYMPTOMS
chronic cough
shortness of breath
EXPOSURE TO RISKFACTORS
tobacco
occupation
indoor/outdoor pollution
SPIROMETRY: Required to establishdiagnosis
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis of COPD
sputum
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Gl b l S f i i d i f CO
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Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of Airflow Limitation:Spirometry
Spirometry should be performed after theadministration of an adequate dose of a short-
acting inhaled bronchodilator to minimizevariability.
A post-bronchodilator FEV1/FVC < 0.70 confirmsthe presence of airflow limitation.
Where possible, values should be compared toage-related normal values to avoid overdiagnosisof COPD in the elderly.
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Spirometry: Normal Trace ShowingFEV1and FVC
1 2 3 4 5 6
1
2
3
4
Volume,
lite
rs
Time, sec
FVC5
1
FEV1= 4LFVC = 5L
FEV1/FVC = 0.8
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Spirometry: Obstructive Disease
Volume,
lite
rs
Time, seconds
5
4
3
2
1
1 2 3 4 5 6
FEV1= 1.8L
FVC = 3.2L
FEV1/FVC = 0.56
Normal
Obstructive
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Determine the severity of the disease, itsimpact on the patients health status and therisk of future events (for example
exacerbations) to guide therapy. Consider thefollowing aspects of the disease separately:
current level of patients symptoms
severity of the spirometric abnormality frequency of exacerbations presence of comorbidities.
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD: Goals
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Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
Assess symptoms
Assess degree of airflowlimitation using spirometry
Assess risk of exacerbations
Assess comorbidities 2013 Global Initiative for Chronic Obstructive Lung Disease
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The characteristic symptoms of COPD are chronic andprogressive dyspnea, cough, and sputum productionthat can be variable from day-to-day.
Dyspnea: Progressive, persistent and characteristicallyworse with exercise.
Chronic cough: May be intermittent and may be
unproductive.
Chronic sputum production: COPD patients commonlycough up sputum.
Global Strategy for Diagnosis, Management and Prevention of COPD
Symptoms of COPD
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Assess symptoms
Assess degree of airflow limitation using
spirometry
Assess risk of exacerbations
Assess comorbidities
Use the COPD Assessment Test(CAT)or
mMRC Breathlessness scale
or
Clinical COPD Questionnaire (CCQ)
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
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COPD Assessment Test (CAT):An 8-itemmeasure of health status impairment in COPD(http://catestonline.org).
Breathlessness Measurement using theModified British Medical Research Council
(mMRC) Questionnaire:relates well to othermeasures of health statusand predicts futuremortality risk.
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of Symptoms
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Clinical COPD Questionnaire (CCQ): Self-administered developed to measure clinicalcontrol in patients with COPD.
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of Symptoms
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Global Strategy for Diagnosis, Management and Prevention of COPD
Modified MRC (mMRC)Questionnaire
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Assess symptoms
Assess degree of airflow limitation
usingspirometryAssess risk of exacerbations
Assess comorbidities
Use spirometry for grading severity
according to spirometry, using four
grades split at 80%, 50% and 30% ofpredicted value
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
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Global Strategy for Diagnosis, Management and Prevention of COPD
Classification of Severity of AirflowLimitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1> 80% predicted
GOLD 2: Moderate 50% < FEV1< 80% predicted
GOLD 3: Severe 30% < FEV1< 50% predicted
GOLD 4: Very Severe FEV1< 30% predicted
*Based on Post-Bronchodilator FEV1 2013 Global Initiative for Chronic Obstructive Lung Disease
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Assess symptoms
Assess degree of airflow limitation
using spirometry Assess risk of exacerbations
Assess comorbiditiesUse history of exacerbations and spirometry.Two exacerbations or more within the last year
or an FEV1 < 50 % of predicted value are
indicators of high risk
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
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Global Strategy for Diagnosis, Management and Prevention of COPD
Assess Risk of Exacerbations
To assess risk of exacerbations usehistory of exacerbations and
spirometry:
Two or more exacerbations within
the last year oran FEV1 < 50 % ofpredicted value are indicators ofhigh risk.
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Assess symptoms
Assess degree of airflow limitation usingspirometry
Assess risk of exacerbations
Combine these assessments for thepurpose of improving management of COPD
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Gl b l S f d f CO
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Risk
(GOLD
ClassificationofA
irflow
Limitation
)
Risk
(Exacerbation
history)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1
CAT < 10
4
3
2
1
mMRC > 2
CAT > 10Symptoms
(mMRC or CAT score)) 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
(C) (D)
(A) (B)mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms(mMRC or CAT score))
If mMRC 0-1 or CAT < 10:
Less Symptoms (A or C)
If mMRC > 2 or CAT > 10:
More Symptoms (B or D)
Assess symptoms first
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Risk
(GOLD
Clas
sificationofAirflo
w
Limitation)
Risk
(E
xacerbationhistory)
> 2
1
0
(C) (D)
(A) (B)mMRC 0-1
CAT < 10
4
3
2
1
mMRC > 2
CAT > 10
Symptoms(mMRC or CAT score))
If GOLD 1 or 2 and only0 or 1 exacerbations per year:
Low Risk (A or B)
If GOLD 3 or 4 ortwo ormore exacerbations per year:
High Risk (C or D)
(One or more hospitalizationsfor COPD exacerbationsshould be considered high
risk.)
Assess risk of exacerbations next
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Risk
(GOLD
Clas
sificationofAirflo
w
Limitation)
Risk
(E
xacerbationhistory)
> 2
1
0
(C) (D)
(A) (B)mMRC 0-1
CAT < 10
4
3
2
1
mMRC > 2
CAT > 10
Symptoms(mMRC or CAT score))
Patient is now in one offour categories:
A: Les symptoms, low risk
B: More symptoms, low risk
C: Less symptoms, high risk
D: More symptoms, high risk
Use combined assessment
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Risk
(GOLD
ClassificationofA
irflow
Limitation
)
Risk
(Exacerbation
history)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1
CAT < 10
4
3
2
1
mMRC > 2
CAT > 10Symptoms
(mMRC or CAT score))
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Global Strategy for Diagnosis, Management and
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Patien
t
Characteristic Spirometric
Classification
Exacerbations
per year
mMRC CAT
ALow Risk
Less SymptomsGOLD 1-2 1 0-1 < 10
B
Low Risk
More Symptoms GOLD 1-2 1 > 2 10
CHigh Risk
Less SymptomsGOLD 3-4 >2 0-1 < 10
DHigh Risk
More SymptomsGOLD 3-4 > 2 > 2
10
Prevention of COPD
Combined Assessment
of COPDWhen assessing risk, choose the highestriskaccording to GOLD grade or exacerbation
history. One or more hospitalizations for COPD
exacerbations should be considered high risk.)
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Global Strategy for Diagnosis, Management and Prevention of COPD
Assess COPD Comorbidities
COPD patients are at increased risk for:
Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes
Lung cancerThese comorbid conditions may influence mortality
and hospitalizations and should be looked for
routinely, and treated appropriately. 2013 Global Initiative for Chronic Obstructive Lung Disease
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Differential Diagnosis:COPD and Asthma
COPD
Onset in mid-life
Symptoms slowlyprogressive
Long smoking history
ASTHMA
Onset early in life (often
childhood) Symptoms vary from day to day
Symptoms worse at night/earlymorning
Allergy, rhinitis, and/or eczemaalso present
Family history of asthma
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Global Strategy for Diagnosis, Management and Prevention of COPD
Additional Investigations
Chest X-ray: Seldom diagnostic but valuable to excludealternative diagnoses and establish presence of significantcomorbidities.
Lung Volumes and Diffusing Capacity:Help to characterizeseverity, but not essential to patient management.
Oximetry and Arterial Blood Gases: Pulse oximetry can beused to evaluate a patients oxygen saturation and need for
supplemental oxygen therapy.Alpha-1 Antitrypsin Deficiency Screening: Perform when COPDdevelops in patients of Caucasian descent under 45 years orwith a strong family history of COPD.
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Exercise Testing: Objectively measured exerciseimpairment, assessed by a reduction in self-paced walkingdistance (such as the 6 min walking test) or duringincremental exercise testing in a laboratory, is a powerfulindicator of health status impairment and predictor ofprognosis.
Composite Scores: Several variables (FEV1, exercise
tolerance assessed by walking distance or peak oxygenconsumption, weight loss and reduction in the arterialoxygen tension) identify patients at increased risk formortality.
Global Strategy for Diagnosis, Management and Prevention of COPD
Additional Investigations
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Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage ComorbiditiesUPDATED 2013
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Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Key Points
Smoking cessation has the greatest capacity toinfluence the natural history of COPD. Health careproviders should encourage all patients who smoketoquit.
Pharmacotherapy and nicotine replacement reliablyincrease long-term smoking abstinence rates.
All COPD patients benefit from regular physicalactivity and should repeatedly be encouraged toremain active.
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Appropriate pharmacologic therapy can reduce COPDsymptoms, reduce the frequency and severity of
exacerbations, and improve health status andexercise tolerance.
None of the existing medications for COPD has beenshown conclusively to modify the long-term decline
in lung function.
Influenza and pneumococcal vaccination should beoffered depending on local guidelines.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Key Points
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Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Smoking Cessation
Counseling delivered by physicians and other healthprofessionals significantly increases quit rates over self-initiated strategies. Even a brief (3-minute) period of
counseling to urge a smoker to quit results in smokingquit rates of 5-10%.
Nicotine replacement therapy (nicotine gum, inhaler,nasal spray, transdermal patch, sublingual tablet, orlozenge) as well as pharmacotherapy with varenicline,bupropion, and nortriptyline reliably increases long-term smoking abstinence rates and are significantlymore effective than placebo.
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Brief Strategies to Help the
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Brief Strategies to Help thePatient Willing to Quit Smoking
ASK Systematically identify all
tobacco users at every visit
ADVISE Strongly urge all tobaccousers to quit
ASSESS Determine willingness to
make a quit attempt
ASSIST Aid the patient in quitting
ARRANGE Schedule follow-up contact. 2013 Global Initiative for Chronic Obstructive Lung Disease
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Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Risk Reduction
Encourage comprehensive tobacco-control policies with clear,consistent, and repeated nonsmoking messages.
Emphasize primary prevention, best achieved by elimination or
reduction of exposures in the workplace. Secondaryprevention, achieved through surveillance and early detection,is also important.
Reduce or avoid indoor air pollution from biomass fuel, burned
for cooking and heating in poorly ventilated dwellings.
Advise patients to monitor public announcements of air qualityand, depending on the severity of their disease, avoid vigorousexercise outdoors or stay indoors during pollution episodes.
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Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: COPD Medications
Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
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Bronchodilator medications are central to the
symptomatic management of COPD.
Bronchodilators are prescribed on an as-needed or on a
regular basis to prevent or reduce symptoms.
The principal bronchodilator treatments are beta2- agonists, anticholinergics, theophylline or combinationtherapy.
The choice of treatment depends on the availability of
medications and each patients individual response in
terms of symptom relief and side effects..
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Bronchodilators
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Long-acting inhaled bronchodilators are
convenient and more effective for symptom reliefthan short-acting bronchodilators.
Long-acting inhaled bronchodilators reduceexacerbations and related hospitalizations andimprove symptoms and health status.
Combining bronchodilators of differentpharmacological classes may improve efficacy anddecrease the risk of side effects compared toincreasing the dose of a single bronchodilator.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Bronchodilators
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Regular treatment with inhaled corticosteroids (ICS)
improves symptoms, lung function and quality of lifeand reduces frequency of exacerbations for COPD
patients with an FEV1< 60% predicted.
Inhaled corticosteroid therapy is associated with anincreased risk of pneumonia.
Withdrawal from treatment with inhaledcorticosteroids may lead to exacerbations in somepatients.
Therapeutic Options: InhaledCorticosteroids
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An inhaled corticosteroid combined with a long-acting
beta2-agonist is more effective than the individualcomponents in improving lung function and health
status and reducing exacerbations in moderate to verysevere COPD.
Combination therapy is associated with an increased riskof pneumonia.
Addition of a long-acting beta2-agonist/inhaledglucorticosteroid combination to an anticholinergic(tiotropium) appears to provide additional benefits.
Therapeutic Options: CombinationTherapy
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Chronic treatment with systemic
corticosteroids should be avoidedbecause of an unfavorable benefit-to-risk ratio.
Therapeutic Options: SystemicCorticosteroids
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Global Strategy for Diagnosis, Management and Prevention of COPD
The pe ti Option
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In patients with severe and very severeCOPD (GOLD 3 and 4) and a history ofexacerbations and chronic bronchitis, thephospodiesterase-4 inhibitor (PDE-4),roflumilast, reduces exacerbations treated
with oral glucocorticosteroids.
Therapeutic Options:Phosphodiesterase-4 Inhibitors
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gy g , g
Therapeutic Options: Theophylline
Theophylline is less effective and less well tolerated thaninhaled long-acting bronchodilators and is notrecommended if those drugs are available and affordable.
There is evidence for a modest bronchodilator effect andsome symptomatic benefit compared with placebo in stableCOPD. Addition of theophylline to salmeterol produces agreater increase in FEV1and breathlessness than
salmeterol alone.
Low dose theophylline reduces exacerbations but does notimprove post-bronchodilator lung function.
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
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Influenza vaccines can reduce serious illness.Pneumococcal polysaccharide vaccine is recommendedfor COPD patients 65 years and older and for COPDpatients younger than age 65 with an FEV1< 40%predicted.
The use of antibiotics, other than for treating infectious
exacerbations of COPD and other bacterial infections, iscurrently not indicated.
Therapeutic Options: OtherPharmacologic Treatments
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Other
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Alpha-1 antitrypsin augmentation therapy:notrecommended for patients with COPD that is unrelatedto the genetic deficiency.
Mucolytics: Patients with viscous sputum maybenefit from mucolytics; overall benefits are very small.
Antitussives: Not recommended.
Vasodilators: Nitric oxide is contraindicated in stableCOPD. The use of endothelium-modulating agents forthe treatment of pulmonary hypertension associatedwith COPD is not recommended.
Therapeutic Options: OtherPharmacologic Treatments
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All COPD patients benefit from exercise trainingprograms with improvements in exercise toleranceand symptoms of dyspnea and fatigue.
Although an effective pulmonary rehabilitationprogram is 6 weeks, the longer the programcontinues, the more effective the results.
If exercise training is maintained at home, thepatient's health status remains above pre-rehabilitation levels.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Rehabilitation
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Oxygen Therapy: The long-term administration ofoxygen (> 15 hours per day) to patients with chronicrespiratory failure has been shown to increase
survival in patients with severe, resting hypoxemia.
Ventilatory Support: Combination of noninvasiveventilation (NIV) with long-term oxygen therapy may
be of some use in a selected subset of patients,particularly in those with pronounced daytimehypercapnia.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Other Treatments
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
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Lung volume reduction surgery (LVRS) is moreefficacious than medical therapy among patientswith upper-lobe predominant emphysema and low
exercise capacity.
LVRSis costly relative to health-care programs notincluding surgery.
In appropriately selected patients with very severeCOPD, lung transplantation has been shown toimprove quality of life and functional capacity.
Therapeutic Options: SurgicalTreatments
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Palliative Care, End-of-life Care, Hospice Care:
Communication with advanced COPD patients
about end-of-life care and advance care planninggives patients and their families the opportunity tomake informed decisions.
G oba S a egy o ag os s, a age e a d e e o o CO
Therapeutic Options: Other Treatments
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Global Strategy for Diagnosis Management and
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Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Major Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage ComorbiditiesUPDATED 2013
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Identification and reduction of exposure to risk factorsare important steps in prevention and treatment.
Individualized assessment of symptoms, airflow
limitation, and future risk of exacerbations should beincorporated into the management strategy.
All COPD patients benefit from rehabilitation andmaintenance of physical activity.
Pharmacologic therapy is used to reduce symptoms,reduce frequency and severity of exacerbations, andimprove health status and exercise tolerance.
Manage Stable COPD: Key Points
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Global Strategy for Diagnosis, Management and Prevention of COPD
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Long-acting formulations of beta2-agonists
and anticholinergics are preferred overshort-acting formulations. Based on efficacy
and side effects, inhaled bronchodilators arepreferred over oral bronchodilators.
Long-term treatment with inhaled
corticosteroids added to long-actingbronchodilators is recommended for patientswith high risk of exacerbations.
Manage Stable COPD: Key Points
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
M S bl COPD K P i
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Long-term monotherapy with oral or inhaled
corticosteroids is not recommended inCOPD.
The phospodiesterase-4 inhibitor roflumilastmay be useful to reduce exacerbations forpatients with FEV1 < 50% of predicted,
chronic bronchitis, and frequentexacerbations.
Manage Stable COPD: Key Points
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
M St bl COPD G l f Th
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Relieve symptoms
Improve exercise tolerance
Improve health status
Prevent disease progression
Prevent and treat exacerbations
Reduce mortality
Reduce
symptoms
Reducerisk
Manage Stable COPD: Goals of Therapy
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Avoidance of risk factors
- smoking cessation
- reduction of indoor pollution
- reduction of occupational exposureInfluenza vaccination
Manage Stable COPD: All COPD Patients
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
M St bl COPD N h l i
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Manage Stable COPD: Non-pharmacologic
Patient
Group
Essential Recommended Depending on local
guidelines
A
Smoking cessation (can
include pharmacologic
treatment)
Physical activity
Flu vaccination
Pneumococcal
vaccination
B, C, D
Smoking cessation (caninclude pharmacologic
treatment)
Pulmonary rehabilitation
Physical activity
Flu vaccination
Pneumococcal
vaccination
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Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
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Manage Stable COPD: Pharmacologic Therapy(Medications in each box are mentioned in alphabetical order, and
therefore not necessarily in order of preference.)
Patient RecommendedFirst choice
Alternative choice Other PossibleTreatments
A
SAMA prn
or
SABA prn
LAMA
or
LABA
or
SABA and SAMA
Theophylline
B
LAMA
or
LABA
LAMA and LABASABA and/orSAMA
Theophylline
C
ICS + LABA
or
LAMA
LAMA and LABA or
LAMA and PDE4-inh. or
LABA and PDE4-inh.
SABA and/orSAMA
Theophylline
D
ICS + LABA
and/or
LAMA
ICS + LABA and LAMA or
ICS+LABA and PDE4-inh. or
LAMA and LABA or
LAMA and PDE4-inh.
Carbocysteine
SABA and/orSAMA
Theophylline
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
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Exa
cerbationsperyear
> 2
1
0
mMRC 0-1
CAT < 10
GOLD 4
mMRC > 2
CAT > 10
GOLD 3
GOLD 2
GOLD 1
SAMAprn
orSABA prn
LABA
orLAMA
ICS + LABA
or
LAMA
g g py
RECOMMENDED FIRST CHOICE
A B
DC
ICS + LABA
and/or
LAMA
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
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> 2
1
0
mMRC 0-1
CAT < 10
GOLD 4
mMRC > 2
CAT > 10
GOLD 3
GOLD 2
GOLD 1
LAMA
or
LABA
or
SABA and SAMA
LAMA and LABA
or
LAMA and PDE4-inh
or
LABA and PDE4-inh
ICS + LABA and LAMA
or
ICS + LABA and PDE4-inh
or
LAMA and LABA
orLAMA and PDE4-inh.
LAMA and LABA
g g py
ALTERNATIVE CHOICE
A
DC
B
Exa
cerbationsperyear
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
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> 2
1
0
mMRC 0-1
CAT < 10
GOLD 4
mMRC > 2
CAT > 10
GOLD 3
GOLD 2
GOLD 1
Theophylline
SABA and/or SAMA
Theophylline
Carbocysteine
SABA and/or SAMA
Theophylline
SABA and/or SAMA
Theophylline
g g py
OTHER POSSIBLE TREATMENTS
A
DC
B
Exa
cerbationsperyear
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gy g , gPrevention of COPD, 2013: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage ComorbiditiesUPDATED 2013
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
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An exacerbation of COPD is:
an acute event characterized by a
worsening of the patients respiratorysymptoms that is beyond normal day-to-day variations and leads to a
change in medication.
Manage Exacerbations
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The most common causes of COPD exacerbationsare viral upper respiratory tract infections andinfection of the tracheobronchial tree.
Diagnosis relies exclusively on the clinicalpresentation of the patient complaining of an acutechange of symptoms that is beyond normal day-to-day variation.
The goal of treatment is to minimize the impact ofthe current exacerbation and to prevent thedevelopment of subsequent exacerbations.
Manage Exacerbations: Key Points
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
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Short-acting inhaled beta2-agonists with or withoutshort-acting anticholinergics are usually thepreferred bronchodilators for treatment of an
exacerbation. Systemic corticosteroids and antibiotics can shorten
recovery time, improve lung function (FEV1) andarterial hypoxemia (PaO2),
and reduce the risk ofearly relapse, treatment failure, and length ofhospital stay.
COPD exacerbations can often be prevented.
Manage Exacerbations: Key Points
2013 Global Initiative for Chronic Obstructive Lung Disease
Consequences Of COPD Exacerbations
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Impact onsymptoms
and lung
function
Negativeimpact on
quality of life
Consequences Of COPD Exacerbations
Increased
economic
costs
Accelerated
lung function
decline
Increased
Mortality
EXACERBATIONS
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
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Arterial blood gas measurements (in hospital): PaO2< 8.0 kPawith or without PaCO2> 6.7 kPa when breathing room airindicates respiratory failure.
Chest radiographs: useful to exclude alternative diagnoses.
ECG: may aid in the diagnosis of coexisting cardiac problems.
Whole blood count: identify polycythemia, anemia or bleeding.
Purulent sputumduring an exacerbation: indication to begin
empirical antibiotic treatment.Biochemical tests: detect electrolyte disturbances, diabetes, andpoor nutrition.
Spirometric tests: not recommended during an exacerbation.
Manage Exacerbations: Assessments
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
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Oxygen: titrate to improve the patients hypoxemia with atarget 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 30-40 mg prednisolone per day for
10-14 days is recommended.
Manage Exacerbations: Treatment Options
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
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Antibiotics should be given to patients with:
Three cardinal symptoms: increased
dyspnea, increased sputum volume, andincreased sputum purulence.
Who require mechanical ventilation.
Manage Exacerbations: Treatment Options
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Exacerbations: Treatment
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Noninvasive ventilation (NIV) for patientshospitalized for acute exacerbations of
COPD:
Improves respiratory acidosis, decreases
respiratory rate, severity of dyspnea,
complications and length of hospital stay.
Decreases mortality and needs for
intubation.GOLD Revision 2011
Options
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Exacerbations: Indications for
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Marked increase in intensity of symptoms
Severe underlying COPD
Onset of new physical signs
Failure of an exacerbation to respond to initialmedical management
Presence of serious comorbidities
Frequent exacerbations Older age
Insufficient home support
g
Hospital Admission
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Prevention of COPD, 2013: Major Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage ComorbiditiesUPDATED 2013
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
M C biditi
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COPD often coexists with other diseases
(comorbidities) that may have a significant
impact on prognosis. In general, presence of
comorbidities should not alter COPD treatment
and comorbidities should be treated as if the
patient did not have COPD.
Manage Comorbidities
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
M C biditi
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Cardiovascular disease (including ischemic
heart disease, heart failure, atrial fibrillation,
and hypertension) is a major comorbidity in
COPD and probably both the most frequent
and most important disease coexisting with
COPD. Benefits of cardioselective beta-blockertreatment in heart failure outweigh potential
risk even in patients with severe COPD.
Manage Comorbidities
2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
M n ge Como biditie
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Osteoporosis andanxiety/depression: often under-diagnosed and associated with poor health status andprognosis.
Lung cancer: frequent in patients with COPD; the mostfrequent cause of death in patients with mild COPD.
Serious infections: respiratory infections are especially
frequent.Metabolic syndrome and manifest diabetes: morefrequent in COPD and the latter is likely to impact on
prognosis.
Manage Comorbidities
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Global Strategy for Diagnosis, Management and
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Prevention of COPD, 2013: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage ComorbiditiesUPDATED 2013
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Global Strategy for Diagnosis, Management
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Prevention of COPD is to a large extent possibleand should have high priority
Spirometry is requiredto make the diagnosis ofCOPD; the presence of a post-bronchodilatorFEV1/FVC < 0.70 confirms the presence ofpersistent airflow limitation and thus of COPD
The beneficial effects of pulmonary rehabilitationand physical activity cannot be overstated
gy g , gand Prevention of COPD, 2013: Summary
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Global Strategy for Diagnosis, Management
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Assessment of COPD requiresassessment of symptoms, degree of
airflow limitation, risk ofexacerbations, and comorbidities
Combined assessment of symptoms
and risk of exacerbations is the basisfor non-pharmacologic andpharmacologic management of COPD
gy g gand Prevention of COPD, 2013: Summary
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Global Strategy for Diagnosis, Management
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Treat COPD exacerbations to minimizetheir impact and to prevent the
development of subsequentexacerbations
Look for comorbiditiesand if present
treat to the same extent as if thepatient did not have COPD
and Prevention of COPD, 2013: Summary
2013 Global Initiative for Chronic Obstructive Lung Disease
WORLD COPD DAY
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WORLD COPD DAY
November 20, 2013
Raising COPD Awareness Worldwide 2013 Global Initiative for Chronic Obstructive Lung Disease
United States Australia
Brazil
C dCroatia
Germany
Ireland
Slovenia Saudi Arabia
Yugoslavia
Bangladesh
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United States
United Kingdom
Argentina
AustraliaAustria
Canada
Chile
Belgium
China
Denmark
Columbia
Croatia
Egypt
Greece
Italy
SyriaHong Kong ROC
Japan
Iceland
India
Korea
Kyrgyzstan
Uruguay
Moldova
Nepal
Macedonia
Malta
Netherlands
New Zealand
Poland
Norway
Portugal
Georgia
Romania
Russia
SingaporeSlovakia
South Afr ica
SpainSweden
Thailand
Switzerland
Ukraine
United Arab Emirates
Taiwan ROC
Venezuela
Vietnam
Peru
ugos av a
France
Mexico
Turkey CzechRepublic
Pakistan
Israel
GOLD National Leaders
PhilippinesYeman
Kazakhstan
Mongolia
Albania
2013 Global Initiative for Chronic Obstructive Lung Disease
GOLD Website Address
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GOLD Website Address
http://www.goldcopd.org
2013 Global Initiative for Chronic Obstructive Lung Disease
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ADDITIONAL SLIDES PREPARED BY
PROFESSOR PETER J. BARNES, MD
NATIONAL HEART AND LUNG INSTITUTE
LONDON, ENGLAND
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor Peter J. Barnes, MD
National Heart and Lung Institute, London UK
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Professor P.J. Barnes, MD, National
Heart and Lung Institute, London UK
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