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GOLD guide for COPD
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  Global Initiative for ChronicObstructiveL ungD isease GLOBAL STRATEGY FOR THE DIAGNOSIS,   MANAGEMENT, AND PREVENTION OF   CHRONIC OBSTRUCTIVE PULMONARY DISEASE   201 9  REPORT  i GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (2019 REPORT)  © 2019 Global Initiative for Chronic Obstructive Lung Disease, Inc.  ii GOLD BOARD OF DIRECTORS (2018)   GOLD SCIENCE COMMITTEE *  (2018)    Alvar Agusti, MD, Chair   Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes  Barcelona, Spain  Bartolome R. Celli, MD Brigham and Women’s Hospital Boston,   Massachusetts, USA  Rongchang Chen, MD Guangzhou Institute of Respiratory Disease  Guangzhou, PRC  Gerard Criner, MD Temple University School of Medicine  Philadelphia, Pennsylvania, USA  Peter Frith, MD Flinders University  Adelaide,    Australia  David Halpin, MD Royal Devon and Exeter Hospital  Devon, UK  M. Victorina López Varela, MD Universidad de la República Montevideo,   Uruguay  Masaharu Nishimura, MD (retired May, 2018) Hokkaido University School of Medicine Sapporo, Japan Sundeep Salvi, MD Chest Research Foundation Pune, India Claus Vogelmeier, MD University of Marburg  Marburg, Germany Claus Vogelmeier, MD, Chair   University of Marburg  Marburg, Germany   Alvar Agusti, MD Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes  Barcelona, Spain   Antonio Anzueto, MD University of Texas Health Science Center   San Antonio, Texas, USA  Peter Barnes, MD National Heart and Lung Institute  London, United Kingdom  Jean Bourbeau, MD McGill University Health Centre  Montreal, Canada Gerard Criner, MD Temple University School of Medicine  Philadelphia, Pennsylvania, USA  Peter Frith, MD Repatriation General Hospital  Adelaide,    Australia  David Halpin, MD Royal Devon and Exeter Hospital Devon, United Kingdom MeiLan Han, MD MS University of Michigan   Ann Arbor, MI, USA Fernando J. Martinez, MD MS New York-Presbyterian Hospital/ Weill Cornell Medical Center   New York, NY, USA   Alberto Papi, MD University of Ferrara Ferrara, Italy Ian Pavord, MA DM University of Oxford Oxford, UK Nicolas Roche, MD University Paris Descartes Hôpital Cochin APHP  Paris, France  Donald Sin, MD St. Paul’s Hospital, University of British Columbia Vancouver, Canada  Dave Singh, MD University of Manchester Manchester, UK  Robert Stockley, MD University Hospital Birmingham, UK  Jørgen Vestbo, MD University of Manchester   Manchester, England, UK  Jadwiga A. Wedzicha, MD Imperial College London London, UK M. Victorina López Varela, MD Universidad de la República Hospital Maciel Montevideo, Uruguay GOLD PROGRAM DIRECTOR  Rebecca Decker, MSJ   Fontana, Wisconsin, USA EDITORIAL ASSISTANCE Ruth Hadfield, PhD, Sydney, Australia  Michael Hess, RRT RPFT, Michigan, USA   *Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org    iii GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF COPD (2019)   GOLD ASSEMBLY  ARGENTINA  Dr Eduardo A. Schiavi Buenos Aires, Argentina AUSTRALIA  Peter Frith, MD Adelaide, South Australia, Australia AUSTRIA  Dr Otto Chris Burghuber BANGLADESH  Prof Md Mostafizur Rahman Dhaka, Bangladesh Dr Kazi S. Bennoor Dhaka, Bangladesh BRAZIL  Aquiles Camelier, MD Sao Paulo, Brazil Fernando Lundgren, MD CANADA  Dr Dennis E. O ’ Donnell Kingston, Ontario, Canada CHILE  Dr Manuel Barros CHINA  Jiangtao Lin, MD Beijing, China Fu-Qiang Wen, MD, PhD Chengdu, Sichuan, China Nan-Shan Zhong, MD Guangzhou, China COLOMBIA  Alejandro Casas, MD Vice-Director, COPD Department Latin American Thoracic Society CROATIA  Neven Miculinic, MD Zagreb, Croatia CZECH REPUBLIC  Stanislav Kos, MD, PhD, FCCP Czech Civic Association Against Lung Diseases Pilsen, Czech Republic DOMINICAN REPUBLIC  Dr Eduardo Gautreau de Windt Provincia Santo Domingo, Dominican Republic EGYPT  Hisham Tarraf, MD Cairo, Egypt EL SALVADOR  Dr Victor Castro Gòmez San Salvador, El Salvador FRANCE  Gaetan Deslée, MD Hôpital Maison Blanche Reims, France GEORGIA  Maia Gotua, MD, PhD Tbilisi, Georgia HONG KONG CHINA  David S.C. Hui, MD Shatin, N.T. Hong Kong INDONESIA  Professor Faisal Yunus IRAN  Dr Masjedi Mohammad Reza Tehran, Iran Mohammad Ashkan Moslehi, MD Shiraz, Iran IRELAND  Timothy J. McDonnell, MD Dublin, Ireland ISRAEL  Zvi G. Fridlender, MD, MSc Jerusalem, Israel ITALY  Professor Lorenzo Corbetta Florence, Italy JAPAN  Takahide Nagase, MD Tokyo, Japan Michiaki Mishima, MD Kyoto, Japan JORDAN  Haytham El-Khushman Amman, Jordan KAZAKHSTAN  Damilya Nugmanova, MD, PhD, DSci Almaty, Kazakhstan KOREA  Yeon-Mok Oh, MD Seoul, South Korea KUWAIT  Professor Mousa Khadadah Kuwait University KYRGYZSTAN  Talant Sooronbaev, MD Bishkek, Kyrgyzstan MALTA  Prof Joseph M Cacciottolo Pieta, Malta LEBANON Mirna Waked, MD Beirut, Lebanon MOLDOVA  Alexandru Corlateanu, MD, PhD ERS National Delegate Republic of Moldova MONGOLIA  Dr Oyunchimeg Chair of International Cooperation NORWAY  Rune Nielsen, MD Bergen, Norway PAKISTAN  Professor Javaid Khan Karachi, Pakistan Dr Mohammad Osman Yusuf Islamabad, Pakistan PHILIPPINES  Teresita S. deGuia, MD Quezon City, Philippines POLAND  Ewa Nizankowska-Mogilnicka,MD,PhD, Krakow, Poland Pawel Śliwiński  Warsaw, Poland Paul Kuca, MD Warsaw, Poland  ROMANIA  Florin Mihaltan, MD Bucharest, Romania Ruxandra Ulmeanu, MD Bucharest, Romania RUSSIA  Alexander Chuchalin, MD Moscow, Russia SINGAPORE  Kian-Chung Ong, MD Wan-Cheng Tan, MD, Chair, Asian Pacific COPD Roundtable SLOVAK REPUBLIC  Ruzena Tkacova, MD PhD Kosice, Slovakia SPAIN  Dr Patricia Sobradillo SYRIA  Yousser Mohammad, MD Lattakia, Syria TURKEY  Prof Dr. Hakan Gunen Malatya, Turkey Nurdan Kokturk, MD Ankara, Turkey URUGUAY  Mará Victorina López, MD Montevideo, Uruguay VENEZUELA  Maria Montes de Oca, MD Caracas, Venezuela VIETNAM  Sy Duong-Quy, MD, PhD, FCCP Lam Dong Medical College, Vietnam Ngo Quy Chau, MD, PhD Hanoi, Vietnam Le Thi Tuyet Lan, MD, PhD Ho Chi Minh City, Vietnam  iv PREFACE In 2011, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) released a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD. It recommended a major revision in the management strategy for COPD that was first presented in the srcinal 2001 document. Reports released in January 2013, January 2014, January 2015, January 2016, January 2017 and January 2018 were based on updated scientific literature published since the completion of the 2011 document but maintain the same treatment paradigm. The 2015 update added an Appendix on Asthma COPD Overlap Syndrome, material prepared jointly by the GOLD and GINA Science Committees. The assessment of COPD proposed by GOLD has been based on the patient’s level of symptoms, future risk of exacerbations, the extent of airflow limitation, the spirometric abnormality, and the identification of comorbidities. The “ABCD” assessment tool of the 2011 GOLD update was a major advance from the simple spirometric grading system of the earlier versions of GOLD because it incorporated multimodality assessment, symptom burden and highlighted the importance of exacerbation prevention in the management of COPD. However, there were some important limitations to this scheme. The ABCD assessment tool performed no better than spirometric grades for mortality prediction or other important health outcomes. To address these and other concerns (while at the same time maintaining consistency and simplicity for the practicing clinician), a refinement of the ABCD assessment tool was proposed in the 2017 GOLD Report that separates spirometric grades from the “ABCD” groups. Thus, ABCD groups and their associated implications for pharmacotherapy recommendations will be derived exclusively from patient symptoms and their history of exacerbations. The separation of airflow limitation from clinical parameters makes it clearer what is being evaluated and ranked. This revised assessment tool acknowledges the limitations of FEV 1  in influencing some therapeutic decisions for individualized patient care and highlights the importance of patient symptoms and exacerbation risks in patients with COPD. Spirometry remains key in the diagnosis, prognostication and treatment with non-pharmacological therapies. The GOLD report has been used worldwide as a “strategy document” for health care professionals to use as a tool to implement effective management programs based on local healthcare systems. The ABCD assessment tool has been used by many to structure their assessment of COPD symptom burden and create treatment plans. The 2017 revision introduced a refinement of the ABCD system by separating spirometric evaluation from analysis of symptoms/exacerbation history with the recommendations for pharmacotherapy being based primarily on the patient needs (symptom reduction and/or exacerbation prevention). Following feedback from GOLD report users, the committee identified there was some misinterpretation regarding the use of the ABCD system. Therefore, in the 2019 revision initial treatment (based on ABCD) is separated from follow-up treatment (based on the patient’ s major treatable trait(s) and the currently used drug(s)). In addition, we introduce the blood eosinophil count as a biomarker for estimating the efficacy of inhaled corticosteroids for the prevention of exacerbations. GOLD has been fortunate to have a network of international distinguished health professionals from multiple disciplines. Many of these experts have initiated investigations of the causes and prevalence
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