만성폐쇄성 폐질환 (COPD) GOLD 가이드라인 2017

만성폐쇄성 폐질환 (COPD) GOLD 가이드라인 2017

GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE

(GOLD) 2017

COPD Definition

Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.

Diagnosis and Initial Assessment

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

Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation.

The goals of COPD assessment are to determine the level of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (such as exacerbations, hospital admissions, or death), in order to guide therapy.

증상과 Risk Factor 가 있어 의심되는 상태에서 Spirometry 시행하여 Post-BDR FEV1/FVC 가 0.7 미만이면 COPD 로 진단이 가능하다. (최근에는 초기에 COPD 를 진단하여 치료를 빨리 시작하자는 움직임이 있고, Risk factor 가 알려지지 않은 요인도 있으므로, 증상과 Risk factor 가 없더라도 COPD 로 진단이 불가능한 것은 아니다.)

* 감별진단 : 천식, 울혈성심부전, 기관지 확장증, 결핵, 폐쇄성 기관지염 (Bronchiolitis obliterans) 미만성 세기관지염 등.

Classification of severity of airflow limitation

* FEV1 30/50/80% 기준으로 나뉘며 총 4가지 분류가 있다.

Choice of thresholds (증상 평가)

COPD Assessment Test (CAT TM)

Modified Medical Research Council (mMRC) questionnaire

* mMRC 2 부터 증상이 심하다고 보기 때문에 2점을 잘 알고 있어야 한다.

Assessment of Exacerbation Risk (악화위험도 평가)

An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy.

COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy.

빈번한 악화 (연간 2회 이상) 의 가장 좋은 예측 인자는 과거 악화 병력.

ABCD Assessment Tool

Example :

Consider two patients:

Both patients with FEV1 < 30% of predicted

Both with CAT scores of 18

But, one with 0 exacerbations in the past year and the other with 3 exacerbations in the past year.

Both would have been labelled GOLD D in the prior classification scheme.

With the new proposed scheme, the subject with 3 exacerbations in the past year would be labelled GOLD grade 4, group D.

The other patient, who has had no exacerbations, would be classified as GOLD grade 4, group B.

* 우리나라의 경우 FEV1 60% 기준으로 (가)(나) / (다) 를 나누었다.

Evidence Supporting Prevention & Maintenance Therapy

Smoking cessation is key. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates.

The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at present.

Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.

Each pharmacologic treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and cost, and the patient’s response, preference and ability to use various drug delivery devices.

Inhaler technique needs to be assessed regularly.

Influenza vaccination decreases the incidence of lower respiratory tract infections.

Pneumococcal vaccination decreases lower respiratory tract infections.

PCV13 and PPSV23, are recommended for all patients ≥ 65 years of age

Pulmonary rehabilitation improves symptoms, quality of life, and physical and emotional participation in everyday activities.

In patients with severe resting chronic hypoxemia, long-term oxygen therapy improves survival.

In patients with stable COPD and resting or exercise-induced moderate desaturation, long-term oxygen treatment should not be prescribed routinely. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen.

In patients with severe chronic hypercapnia and a history of hospitalization for acute respiratory failure, long-term non-invasive ventilation may decrease mortality and prevent re-hospitalization.

In select patients with advanced emphysema refractory to optimized medical care, surgical or bronchoscopic interventional treatments may be beneficial.

Palliative approaches are effective in controlling symptoms in advanced COPD.

...

Pharmacologic Therapy

* Inhaler 종류

Onbrez breezhaler – indacaterol maleate (LABA)

Ventolin nebules – salbutamol (SABA)

Ventolin evohaler – salbutamol (SABA)

Alvesco – ciclesonide (ICS)

Budecort – budesonide (ICS)

Atrovent – ipratropium (SAMA)

Spiriva respimat – tiotropium (LAMA)

Spiriva handihilar – tiotropium (LAMA)

Anoro – vilanterol, umeclidinium (LABA + LAMA)

Flutiform inhaler – fluticasone, formoterol (ICS + LABA)

Foster – beclomethasone, formoterol (ICS + LABA)

Seretide – Salmeterol, fluticasone (ICS + LABA)

Symbicort – budesonide, fomoterol (ICS + LABA)

Xoterna breezhaler – indacaterol, glycopyrronium (LABA + LAMA)

Management of Stable COPD

Once COPD has been diagnosed, effective management should be based on an individualized assessment to reduce both current symptoms and future risks of exacerbations.

Identify and reduce exposure to known risk factors (s)

Identification and reduction of exposure to risk factors is important in the treatment and prevention of COPD.

Cigarette smoking is the most commonly encountered and easily identifiable risk factor for COPD, and smoking cessation should be continually encouraged for all individuals who smoke.

Reduction of total personal exposure to occupational dusts, fumes, and gases, and to indoor and outdoor air pollutants, should also be addressed.

Pharmacologic treatment (s)

Pharmacologic therapies can reduce symptoms, and the risk and severity of exacerbations, as well as improve health status and exercise tolerance.

Most of the drugs are inhaled so proper inhaler technique is of high relevance.

Pharmacologic treatment algorithms

Group A

All Group A patients should be offered bronchodilator treatment based on its effect on breathlessness. This can be either a short- or a long-acting bronchodilator.

This should be continued if symptomatic benefit is documented.

Group B

Initial therapy should consist of a long acting bronchodilator. Long-acting inhaled bronchodilators are superior to short-acting bronchodilators taken as needed i.e., pro re nata (prn) and are therefore recommended.

There is no evidence to recommend one class of long-acting bronchodilators over another for initial relief of symptoms in this group of patients. In the individual patient, the choice should depend on the patient’s perception of symptom relief.

For patients with persistent breathlessness on monotherapy the use of two bronchodilators is recommended.

For patients with severe breathlessness initial therapy with two bronchodilators may be considered.

If the addition of a second bronchodilator does not improve symptoms, we suggest the treatment could be stepped down again to a single bronchodilator.

Group B patients are likely to have comorbidities that may add to their symptomatology and impact their prognosis, and these possibilities should be investigated.

Group C

Initial therapy should consist of a single long acting bronchodilator. In two head-to head comparisons the tested LAMA was superior to the LABA regarding exacerbation prevention, therefore we recommend starting therapy with a LAMA in this group.

Patients with persistent exacerbations may benefit from adding a second long acting bronchodilator (LABA/LAMA) or using a combination of a long acting beta2-agonist and an inhaled corticosteroid (LABA/ICS). As ICS increases the risk for developing pneumonia in some patients, our primary choice is LABA/LAMA.

Group D

We recommend starting therapy with a LABA/LAMA combination because:

In studies with patient reported outcomes as the primary endpoint LABA/LAMA combinations showed superior results compared to the single substances. If a single bronchodilator is chosen as initial treatment, a LAMA is preferred for exacerbation prevention based on comparison to LABAs.

A LABA/LAMA combination was superior to a LABA/ICS combination in preventing exacerbations and other patient reported outcomes in Group D patients.

Group D patients are at higher risk of developing pneumonia when receiving treatment with ICS.

In some patients initial therapy with LABA/ICS may be the first choice. These patients may have a history and/or findings suggestive of asthma-COPD overlap. High blood eosinophil counts may also be considered as a parameter to support the use of ICS, although this is still under debate.

In patients who develop further exacerbations on LABA/LAMA therapy we suggest two alternative pathways:

Escalation to LABA/LAMA/ICS. Studies are underway comparing the effects of LABA/LAMA vs. LABA/LAMA/ICS for exacerbation prevention.

Switch to LABA/ICS. However, there is no evidence that switching from LABA/LAMA to LABA/ICS results in better exacerbation prevention. If LABA/ICS therapy does not positively impact exacerbations/symptoms, a LAMA can be added.

If patients treated with LABA/LAMA/ICS still have exacerbations the following options may be considered:

Add roflumilast. This may be considered in patients with an FEV1 < 50% predicted and chronic bronchitis, particularly if they have experienced at least one hospitalization for an exacerbation in the previous year.

Add a macrolide. The best available evidence exists for the use of azithromycin. Consideration to the development of resistant organisms should be factored into decision making.

Stopping ICS. A reported lack of efficacy, an elevated risk of adverse effects (including pneumonia) and evidence showing no significant harm from withdrawal supports this recommendation.

Non-Pharmacologic Treatment

- 금연, 신체활동 권유, 예방주사 (독감, 폐렴알균) --> GOLD A/B/C/D

- 호흡재활 --> GOLD B/C/D

Interventional bronchoscopy and surgery (s)

In selected patients with heterogeneous or homogenous emphysema and significant hyperinflation refractory to optimized medical care, surgical or bronchoscopic modes of lung volume reduction (e.g., endobronchial one-way valves or lung coils) may be considered.

In selected patients with a large bulla, surgical bullectomy may be considered.

In selected patients with very severe COPD and without relevant contraindications, lung transplantation may be considered.

...

Management of Exacerbations

An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy.

Exacerbations of COPD can be precipitated by several factors. The most common causes are respiratory tract infections.

Short-acting inhaled beta2-agonists (ventolin), with or without short-acting anticholinergics (atrovent), are recommended as the initial bronchodilators to treat an acute exacerbation. (evidence C)

Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge.

Systemic corticosteroids can improve lung function (FEV1), oxygenation and shorten recovery time and hospitalization duration. Duration of therapy should not be more than 5-7 days. (evidence A)

Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalization duration. Duration of therapy should be 5-7 days. (evidence B)

Methylxanthines are not recommended due to increased side effect profiles. (evidence B)

Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindication because it improves gas exchange, reduces work of breathing and the need for intubation, decreases hospitalization duration and improves survival. (evidence A)

Pharmacologic treatment  (s)

The three classes of medications most commonly used for COPD exacerbations are:

Bronchodilators

Although there is no high-quality evidence from RCTs, it is recommended that short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, are the initial bronchodilators for acute treatment of a COPD exacerbation.

Corticosteroids

Data from studies indicate that systemic glucocorticoids in COPD exacerbations shorten recovery time and improve lung function (FEV1). They also improve oxygenation, the risk of early relapse, treatment failure, and the length of hospitalization.

Antibiotics

** COPD 급성 악화에서 IV aminophylline 의 role 은 줄어들고 있다.

Respiratory support

끝.

2018. 10. 8 - SJH