Hoble new concept of treatment by gold. Hoble - national recommendations. 2 Surgical treatment

Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (Version January 2017, European Respiratory Medical Journal)

Global Strategy for Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease 2017 (Report) European Respiratory Medical Journal. Posted on January 30, 2017 Copyright 2017 by the European Respiratory Society. annotation This summary of the Global Strategy for the Diagnosis, Management and Prevention of COPD (GOLD) 2017 report focuses on the revised and new portions of the document. The most significant changes include: i) The COPD score has been improved to separate the spirometry score from the symptom score. ABCD groups are now offered exclusively for the patient's symptoms and history of exacerbations; ii) for each of the groups from A-D, an escalation strategy for pharmacological treatment is proposed; iii) introduce the concept of therapy de-escalation into the treatment evaluation scheme; iv) non-pharmacological therapies are comprehensively presented; c) the significance of comorbid conditions in the management of COPD is considered. Content Introduction Definition and factors influencing the development and progression of COPD Key points Definition and pathogenesis Diagnosis and Initial Evaluation Key Points Diagnostics Symptoms Dyspnea Cough Sputum production Wheezing and tightness in the chest Additional characteristics of severe disease Disease history Physical examination Spirometry Expert Questions Airflow limitation severity classification Symptom assessment Choice of exacerbation risk assessment Blood eosinophilia count Revised Comprehensive Assessment of COPD Example Alpha-1 antitrypsin deficiency Additional Research Combined rating scales Differential diagnoses Other considerations Prevention and supportive care Key Points To give up smoking Nicotine replacement products Pharmacological agent Smoking cessation programs Vaccinations Influenza Vaccines and Pneumococcal Vaccines Pharmacological therapy for stable COPD Drug Overview Bronchodilators beta2 agonists, Antimuscarinic drugs Methylxanthines Combined bronchodilator therapy Anti-inflammatory drugs ICS withdrawal Triple inhalation therapy Oral glucocorticoids Phosphodiesterase-4 inhibitors Antibiotics Mucolytics (mucokinetics, mucoregulators) and antioxidants (N-acetylcysteine, carbocysteine) Other drugs with anti-inflammatory potential associated with inhalation therapy Alpha-1 Antitrypsin Boosting Therapy Antitussives Vasodilators Pulmonary rehabilitation Education Self management Comprehensive Care Programs Support, Palliative, End of Life, and Hospice Care End of Life and Hospice Care Other treatments Oxygen Therapy and Respiratory Support oxygen therapy Fan support Interventional Therapy Surgical Interventions Lung Volume Reduction Surgery Bullectomy Lung transplant Bronchoscopic interventions to reduce airiness in severe emphysema Management of stable COPD Key points Identifying and reducing exposure to risk factors Treatment of stable COPD Medical treatment pharmacological treatment algorithms Group A Group B Group C Group D Non-pharmacological treatment Education and self-management end of life and palliative care Nutritional support Vaccination oxygen therapy Respiratory Support Non-invasive ventilation Invasive ventilation Hospital discharges and follow-up Prevention of exacerbations COPD and comorbidities (comorbidity) Key points Cardiovascular diseases Heart failure Cardiac ischemia arrhythmias Peripheral vascular disease hypertension Osteoporosis Anxiety and depression COPD and lung cancer Metabolic syndrome and diabetes mellitus Gastroesophageal Reflux bronchiectasis Obstructive Sleep Apnea Introduction This summary of the Global Strategy for the Diagnosis, Management and Prevention of COPD (GOLD) 2017 report is based on scientific publications up to October 2016. Evidence levels are assigned evidence-based recommendations where appropriate. Categories used to assess the level of evidence presented in Table S1 in the Supplementary Appendix. Definition and factors influencing the development and progression of COPD Definition and factors influencing the development and progression of COPD

• Supplementary Appendix

The goals of COPD treatment can be divided into 4 main groups:
Relieve symptoms and improve quality of life;
Reducing future risks, etc; prevention of exacerbations;
Slowing down the progression of the disease;
Decreased mortality.
COPD therapy includes pharmacological and non-pharmacological approaches. Pharmacological treatments include bronchodilators, combinations of ICS and long-acting bronchodilators (LABD), phosphodiesterase-4 inhibitors, theophylline, and influenza and pneumococcal vaccinations.
Non-pharmacological options include smoking cessation, pulmonary rehabilitation, oxygen therapy, respiratory support, and surgical management.
The treatment of exacerbations of COPD is considered separately.

3.1 Conservative treatment.

To give up smoking.

Choice of inhaler.

Management of stable COPD.

3.2 Surgical treatment.

3.3 Other treatments.

Long-term oxygen therapy.

Prolonged home ventilation.

The classification of COPD (chronic obstructive pulmonary disease) is broad and includes a description of the most common stages of the disease and the variants in which it occurs. And although not all patients progress COPD according to the same scenario and not all can be identified as a certain type, the classification always remains relevant: most patients fit into it.

Stages of COPD

The first classification (COPD spirographic classification), which determined the stages of COPD and their criteria, was proposed back in 1997 by a group of scientists united in a committee called the World COPD Initiative (in English, the name sounds "Global Initiative for chronic Obstructive Lung Disease" and abbreviated as GOLD). According to her, there are four main stages, each of which is determined mainly by FEV - that is, the volume of forced expiratory flow in the first second:

• COPD 1 degree does not differ in special symptoms. The lumen of the bronchi is narrowed quite a bit, the air flow is also limited not too noticeably. The patient does not experience difficulties in everyday life, experiences shortness of breath only during active physical exertion, and a wet cough - only occasionally, with a high probability at night. At this stage, few people go to the doctor, usually because of other diseases.
• COPD 2 degree becomes more pronounced. Shortness of breath begins immediately when trying to engage in physical activity, cough appears in the morning, accompanied by a noticeable sputum discharge - sometimes purulent. The patient notices that he has become less hardy, and begins to suffer from recurring respiratory diseases - from a simple SARS to bronchitis and pneumonia. If the reason for going to the doctor is not suspicion of COPD, then sooner or later the patient still gets to him because of concomitant infections.
• COPD grade 3 is described as a difficult stage - if the patient has enough strength, he can apply for disability and confidently wait for a certificate to be issued to him. Shortness of breath appears even with minor physical exertion - up to climbing a flight of stairs. The patient is dizzy, dark in the eyes. Cough appears more often, at least twice a month, becomes paroxysmal in nature and is accompanied by chest pains. At the same time, the appearance changes - the chest expands, veins swell on the neck, the skin changes color either to cyanotic or pinkish. Body weight either sharply decreases or sharply decreases.
• Stage 4 COPD means that you can forget about any ability to work - the air flow entering the patient's lungs does not exceed thirty percent of the required volume. Any physical effort - up to changing clothes or hygiene procedures - causes shortness of breath, wheezing in the chest, dizziness. The breathing itself is heavy, labored. The patient has to constantly use an oxygen cylinder. In the worst cases, hospitalization is required.

However, in 2011, GOLD concluded that such criteria are too vague, and it is wrong to make a diagnosis solely on the basis of spirometry (which determines the volume of exhalation). Moreover, not all patients developed the disease sequentially, from a mild stage to a severe stage - in many cases, determining the stage of COPD was impossible. A CAT questionnaire was developed, which is filled in by the patient himself and allows you to determine the condition more fully. In it, the patient needs to determine, on a scale of one to five, how pronounced his symptoms are:

• cough - one corresponds to the statement "no cough", five "constantly";
• sputum - one is “no sputum”, five is “sputum is constantly coming out”;
• a feeling of tightness in the chest - “no” and “very strong”, respectively;
• shortness of breath - from "no shortness of breath at all" to "shortness of breath with the slightest exertion";
• household activity - from "without restrictions" to "very limited";
• leaving the house - from "confidently out of necessity" to "not even out of necessity";
• sleep - from "good sleep" to "insomnia";
• energy - from "full of energy" to "no energy at all."

The result is determined by scoring. If there are less than ten of them, the disease has almost no effect on the patient's life. Less than twenty, but more than ten - has a moderate effect. Less than thirty - has a strong influence. More than thirty - has a huge impact on life.

Objective indicators of the patient's condition, which can be recorded using instruments, are also taken into account. The main ones are oxygen tension and hemoglobin saturation. In a healthy person, the first value does not fall below eighty, and the second does not fall below ninety. In patients, depending on the severity of the condition, the numbers vary:

• with relatively mild - up to eighty and ninety in the presence of symptoms;
• in the course of moderate severity - up to sixty and eighty;
• in severe cases - less than forty and about seventy-five.

After 2011, according to GOLD, COPD no longer has stages. There are only degrees of severity, which indicate how much air enters the lungs. And the general conclusion about the patient's condition does not look like "is at a certain stage of COPD", but as "is in a certain risk group for exacerbations, adverse effects and death due to COPD." There are four in total.

• Group A - low risk, few symptoms. A patient belongs to the group if he had no more than one exacerbation in a year, he scored less than ten points on CAT, and shortness of breath occurs only during exertion.
• Group B - low risk, many symptoms. The patient belongs to the group if there was no more than one exacerbation, but shortness of breath occurs frequently, and more than ten points were scored on CAT.
• Group C - high risk, few symptoms. The patient belongs to the group if he had more than one exacerbation per year, dyspnea occurs during exercise, and the CAT score is less than ten points.
• Group D - high risk, many symptoms. More than one exacerbation, shortness of breath occurs with the slightest exertion, and more than ten points on CAT.

The classification, although it was made in such a way as to take into account the condition of a particular patient as much as possible, still did not include two important indicators that affect the life of the patient and are indicated in the diagnosis. These are COPD phenotypes and comorbidities.

Phenotypes of COPD

In chronic obstructive pulmonary disease, there are two main phenotypes that determine how the patient looks and how the disease progresses.

bronchitis type:

• Cause. The cause of it is chronic bronchitis, relapses of which occur for at least two years.
• Changes in the lungs. The fluorography shows that the walls of the bronchi are thickened. On spirometry, it can be seen that the air flow is weakened and only partially enters the lungs.
• The classic age of discovery is fifty or older.
• Features of the patient's appearance. The patient has a pronounced cyanotic skin color, the chest is barrel-shaped, body weight usually grows due to increased appetite and may approach the border of obesity.
• The main symptom is a cough, paroxysmal, with abundant purulent sputum.
• Infections - often, because the bronchi are not able to filter the pathogen.
• Deformation of the heart muscle of the type "cor pulmonale" - often.

Cor pulmonale is a concomitant symptom in which the right ventricle enlarges and the heart rate accelerates - in this way the body tries to compensate for the lack of oxygen in the blood:

• X-ray. It can be seen that the heart is deformed and enlarged, and the pattern of the lungs is enhanced.
• Diffuse capacity of the lungs - that is, the time it takes for gas molecules to enter the blood. Normally, if it decreases, then not much.
• Forecast. According to statistics, the bronchitis type has a higher mortality rate.

People call the bronchitis type “blue edema” and this is a fairly accurate description - a patient with this type of COPD is usually pale blue, overweight, coughs constantly, but is alert - shortness of breath does not affect him as much as patients with another type.

emphysematous type:

• Cause. The cause is chronic emphysema.
• Changes in the lungs. On fluorography, it is clearly seen that the partitions between the alveoli are destroyed and air-filled cavities are formed - bullae. With spirometry, hyperventilation is recorded - oxygen enters the lungs, but is not absorbed into the blood.
• The classic age of discovery is sixty or older.
• Features of the patient's appearance. The patient has a pink skin color, the chest is also barrel-shaped, veins swell on the neck, body weight decreases due to decreased appetite and may approach the border of dangerous values.
• The main symptom is shortness of breath, which can be observed even at rest.
• Infections are rare, because the lungs still cope with filtering.
• Deformation of the type "cor pulmonale" is rare, the lack of oxygen is not so pronounced.
• X-ray. The picture shows the bullae and deformity of the heart.
• Diffuse ability - obviously greatly reduced.
• Forecast. According to statistics, this type has a longer life expectancy.

The emphysematous type is popularly called the “pink puffer” and this is also quite accurate: a patient with this type of hodl is usually thin, with an unnaturally pink skin color, constantly suffocates and prefers not to leave the house once again.

If a patient has signs of both types, they speak of a mixed COPD phenotype - it occurs quite often in a wide variety of variations. Also in recent years, scientists have identified several subtypes:

• with frequent exacerbations. It is set if the patient is sent to the hospital with exacerbations at least four times a year. Occurs in stages C and D.
• With bronchial asthma. Occurs in a third of cases - with all the symptoms of COPD, the patient experiences relief if he uses drugs to combat asthma. He also has asthma attacks.
• Early start. It is characterized by rapid progress and is explained by a genetic predisposition.
• At a young age. COPD is a disease of the elderly, but can also affect younger people. In this case, it is, as a rule, many times more dangerous and has a high mortality rate.

Concomitant diseases

With COPD, the patient has a great chance to suffer not only from the obstruction itself, but also from the diseases that accompany it. Among them:

• Cardiovascular disease, from coronary heart disease to heart failure. They occur in almost half of the cases and are explained very simply: with a lack of oxygen in the body, the cardiovascular system experiences great stress: the heart moves faster, blood flows faster through the veins, the lumen of the vessels narrows. After some time, the patient begins to notice chest pains, fluctuating pulse, headaches and increased shortness of breath. A third of patients whose COPD is accompanied by cardiovascular diseases die from them.
• Osteoporosis. Occurs in a third of cases. Not fatal, but very unpleasant and also provoked by a lack of oxygen. Its main symptom is bone fragility. As a result, the patient's spine is bent, posture deteriorates, the back and limbs hurt, night cramps in the legs and general weakness are observed. Decreased stamina, finger mobility. Any fracture heals for a very long time and can be fatal. Often there are problems with the gastrointestinal tract - constipation and diarrhea, which are caused by the pressure of the curved spine on the internal organs.
• Depression. It occurs in almost half of the patients. Often its dangers remain underestimated, and meanwhile the patient suffers from decreased tone, lack of energy and motivation, suicidal thoughts, increased anxiety, feelings of loneliness and learning problems. Everything is seen in a gloomy light, the mood is constantly depressed. The reason is both the lack of oxygen and the impact that COPD has on the patient's life. Depression is not fatal, but it is difficult to treat and significantly reduces the pleasure that the patient could get from life.
• Infections. They occur in seventy percent of patients and cause death in a third of cases. This is explained by the fact that the lungs affected by COPD are very vulnerable to any pathogen, and it is difficult to remove inflammation in them. Moreover, any increase in sputum production is a decrease in airflow and a risk of respiratory failure.
• Sleep apnea syndrome. With apnea, the patient stops breathing at night for longer than ten seconds. As a result, he suffers from constant oxygen starvation and may even die from respiratory failure.
• Crayfish. It occurs frequently and causes death in one out of five cases. It is explained, like infections, by the vulnerability of the lungs.

In men, COPD is often accompanied by impotence, and in the elderly it causes cataracts.

Diagnosis and disability

The formulation of the diagnosis of COPD implies a whole formula that doctors follow:

1. the name of the disease is chronic lung disease;
2. COPD phenotype - mixed, bronchitis, emphysematous;
3. the severity of bronchial obstruction - from mild to extremely severe;
4. severity of COPD symptoms - determined by CAT;
5. frequency of exacerbations - more than two frequent, less rare;
6. accompanying illnesses.

As a result, when the examination is completed according to the plan, the patient receives a diagnosis that sounds, for example, like this: “chronic obstructive pulmonary disease of the bronchitis type, II degree of bronchial obstruction with severe symptoms, frequent exacerbations, aggravated by osteoporosis.”

Based on the results of the examination, a treatment plan is drawn up and the patient can apply for disability - the more severe the COPD, the more likely it is that the first group will be delivered.

And although COPD is not treated, the patient must do everything in his power to maintain his health at a certain level - and then both the quality and duration of his life will increase. The main thing is to remain optimistic in the process and not to neglect the advice of doctors.

5
1 Federal State Budgetary Educational Institution of Higher Education USMU of the Ministry of Health of Russia, Yekaterinburg
2 NSMU of the Ministry of Health of Russia, Novosibirsk
3 FGBOU VO South Ural State Medical University of the Ministry of Health of Russia, Chelyabinsk
4 FGBOU VO TSMU of the Ministry of Health of Russia, Vladivostok
5 NSMU of the Ministry of Health of Russia, Novosibirsk, Russia

Currently, chronic obstructive pulmonary disease (COPD) is a global problem due to the high prevalence of the disease and high mortality. The main cause of death in patients with COPD is the progression of the underlying disease. In 2016–2017 several major authoritative events have been held to discuss the therapeutic options for treating patients with COPD, taking into account phenotypes, the need to prevent exacerbations, as well as the features of inhalation therapy.
Despite the priority in the treatment of COPD patients with inhaled long-acting bronchodilators, the authors' goal was to draw the reader's attention to therapy with fixed combinations of inhaled glucocorticosteroids (IGCS) / long-acting β2-agonists (LABA), emphasizing the priority of the extrafine inhaled aerosol form in COPD, and combinations IGCS/LABA in combination with long-acting anticholinergics (LACA). An analysis is given of recommendations and clinical observations on the treatment of this nosology, as well as studies aimed at studying the efficacy and safety of the triple combination of ICS/LABA/LAAD compared with the efficacy and safety of other options for regular COPD therapy.

Keywords: COPD, inhalation therapy, recommendations, inhaled glucocorticosteroids, long-acting β2-agonists, extrafine aerosols.

For citation: Leshchenko I.V., Kudelya L.M., Ignatova G.L., Nevzorova V.A., Shpagina L.A. Resolution of the Council of Experts "The place of anti-inflammatory therapy in COPD in real clinical practice" dated April 8, 2017, Novosibirsk // BC. 2017. No. 18. S. 1322-1324

Resolution of the Board of Experts "Place of anti-inflammatory therapy in COPD in real clinical practice" dated April 8th, 2017, Novosibirsk

Leshchenko I.V. 1 , Kudelya L.M. 2 , Ignatova G.L. 3, Nevzorova V.A. 4, Shpagina L.A. 2

1 Ural State Medical University, Yekaterinburg, Russia
2 Novosibirsk State Medical University, Russia
3 South-Ural State Medical University, Chelyabinsk, Russia
4 Pacific State Medical University, Vladivistok, Russia

Currently, chronic obstructive pulmonary disease (COPD) represents a global problem, which is associated with the prevalence of the disease and high mortality. The main cause of the death of patients with COPD is the progression of the disease. In 2016-2017 years there were a number of major authoritative meetings, where the therapeutic options of the treatment of patients with COPD were discussed, taking into account the phenotypes, the need of prevention of exacerbations, as well as the features of inhalation therapy. Despite the fact that the inhaled long-acting bronchodilators take the first place in the treatment of COPD patients, the aim of the authors was to draw the reader's attention to the therapy with fixed combinations of inhaled glucocorticosteroids (ICS) / long-acting β 2 -agonists (LABA), emphasizing the priority of the extra-fine particles aerosols in COPD, and a combination of ICS / LABA together with long-acting anticholinergics (LAMA). , as well as results of comparative studies of efficacy and safety of the triple combination ICS / LABA / LAMA versus other COPD therapies presented.

key words: COPD, inhalation therapy, recommendations, inhaled glucocorticosteroids, long-acting β 2 -agonists, extra-fine-particles aerosols.
For quote: Leshchenko I.V., Kudelya L.M., Ignatova G.L. et al. Resolution of the Board of Experts "Place of anti-inflammatory therapy in COPD in real clinical practice" dated April 8th, 2017, Novosibirsk // RMJ. 2017. No. 18. P. 1322–1324.

The resolution of the council of experts "The place of anti-inflammatory therapy in COPD in real clinical practice" dated April 8, 2017, Novosibirsk

Research transparency. The authors did not receive grants, remuneration or sponsorship in the preparation of this article. The authors are solely responsible for providing the final version of the manuscript for publication.
Declaration of financial and other relationships. The authors took part in the development of the concept, design of the work and in the writing of the
copies. The final version of the manuscript was approved by all authors.

In 2017, the next revision of the Global Strategy for the Diagnosis, Treatment and Prevention of COPD was published, containing significant changes both in patient stratification and in the therapy choice scheme.
Currently, COPD is a global problem, which is associated with a high prevalence and high mortality.
In a published cross-sectional epidemiological study conducted in 12 regions of Russia (under the GARD program) and including 7164 people (mean age 43.4 years), the prevalence of COPD among people with respiratory symptoms was 21.8%, and in the general population - 15 .3%.
According to WHO, today COPD is the 3rd leading cause of death in the world, about 2.8 million people die from COPD every year, which is 4.8% of all causes of death. About 10–15% of all COPD cases are occupational COPD, which enhances the social significance of the disease.
The main cause of death in patients with COPD is the progression of the underlying disease. Approximately 50–80% of COPD patients die from respiratory causes associated with progressive respiratory failure, pneumonia, or from severe cardiovascular disease or malignancy.
In 2016–2017 several major authoritative events have been held to discuss the therapeutic options for treating patients with COPD, taking into account phenotypes, the need to prevent exacerbations, as well as the features of inhalation therapy.

Treatment

Literature

1. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://www.goldcopd.org
2. Fishwick D., Sen D., Barber C. et al. Occupational chronic obstructive pulmonary disease: a standard of care // Occup Med (Lond). 2015. Vol. 65(4). P. 270–282.
3. Clinical recommendations of the Russian respiratory society. Chronic obstructive pulmonary disease [Electronic resource]. 2016. URL: http://pulmonology.ru. 2016. URL: http://pulmonology.ru (in Russian)].
4. Hogg J.C. Pathophysiology of airflow limitation in chronic obstructive pulmonary disease // Lancet. 2004 Vol. 364. P. 709–721.
5. Hogg J.C., Chu F., Utokaparch S. et al. The Nature of Small-Airway Obstruction in Chronic Obstructive Pulmonary Disease // N Engl J Med. 2004 Vol. 350. P. 2645–2653.
6. Hogg J.C., Chu F.S.F., Tan W.C. et al. Survival after Lung Volume Reduction in Chronic Obstructive Pulmonary Disease. Insights from Small Airway Pathology // Am J Respir Crit Care Med. 2007 Vol. 176. P. 454–459.
7. Singh D. Comparison of extra fine beclomethasone dipropionate/formoterol fumarate versus other double combinations on reduction of moderate/severe exacerbations. Report at ATS, 05/18/2016.
8. Wedzicha J.A., Banerji D., Chapman K.R. et al. Indacaterol–Glycopyrronium versus Salmeterol–Fluticasone for COPD // N Engl J Med. 2016. Vol. 374. P. 2222–2234.
9. PRAC reviews known risk of pneumonia with inhaled corticosteroids for chronic obstructive pulmonary disease. URL: http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2016/03/news_detail_002491.jspandmid=WC0b01ac058004d5c1.
10. Festic E., Bansal V., Gupta E., Scanion P.D. Association of Inhaled Corticosteroids with Incident Pneumonia and Mortality in COPD Patients; Systematic Review and Meta-Analysis // COPD. 2016. Vol. 13. P. 312–326.
11. Kerwin E. A new alphabet for COPD care // Eur Respir J. 2016. Vol. 48. P. 972–975.

12.10.2017

The Global Strategy for the Diagnosis, Management and Prevention of COPD (GOLD) is a document that every practicing physician in Europe dealing with patients with COPD is guided by today. The prevalence of diseases occurring with symptoms of broncho-obstructive syndrome (BOS), in particular COPD, is growing every year.

At the same time, science and medicine do not stand still, methods of treating BOS are constantly being improved, new drugs and their combinations are being created, devices for drug delivery are being improved, and the evidence base for certain drugs is being replenished. That is why the authors of the GOLD strategy consider it necessary to reflect the dynamics of the success of the global fight against COPD on a regular basis, releasing annual updates of the advisory document. So, in February 2017, another update of GOLD recommendations was released. What changes does the updated GOLD‑2017 guide contain? Let's try to understand in detail.

GOLD-2017: changes compared to the 2016 version

Main changes:

Revised definition of COPD;

A new, improved principle for assessing membership in ABCD groups is presented;

A new algorithm for pharmacological treatment with the possibility of escalation and de-escalation is presented.

Definition.“COPD is a common preventable and treatable disease characterized by persistent respiratory symptoms and airflow limitation resulting from airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases.”

Patients are stratified into ABCD groups for subsequent treatment choices based on symptom assessment (using standard CAT or mMRC questionnaires) and a history of exacerbations. Spirometry data, together with symptoms and history of exacerbations, remain an important aspect of diagnosis, prognosis, and the decision on other necessary therapeutic approaches.

In addition, for the first time presented COPD pharmacotherapy algorithm– a shift towards a more personalized approach with a strategy to escalate or de-escalate therapy within a group of patients.

GOLD‑2017: changes in assessment

The basic principles for assessing the severity of COPD in the 2017 sample are shown in Figure 1.

OVF 1 – forced expiratory volume in 1 s;

FVC - forced vital capacity.

Classification of patients according to GOLD‑2017

Group A: low risk of exacerbations, few symptoms.

Group B: low risk of exacerbations, many symptoms.

Group C: high risk of exacerbations, few symptoms.

Group D: high risk of exacerbations, many symptoms.

mMRC 0-1 point or CAT<10 баллов означает «мало симп­томов».

mMRC ≥2 points or CAT ≥10 points means "many symptoms".

"Low risk of exacerbations": 0 or 1 exacerbation (no hospitalization) in the previous year.

"High risk of exacerbations": ≥2 exacerbations or ≥1 exacerbation resulting in hospitalization in the previous year.

Major changes in the treatment algorithm

Pharmacotherapy is determined on the basis of clinical characteristics, the degree of airflow limitation is not a determining factor.

The combination of a long-acting β-adrenergic agonist (LAMA)/long-acting M-anticholinergic (LCDA) has become the first choice for most patients.

The main changes in the choice of therapy are reflected in Figure 2.

Group A

All patients in group A should be given bronchodilators, depending on their effect on dyspnea. These can be both short-acting and long-acting drugs.

This treatment can be continued if there is a positive effect on the symptoms.

Group B

A long-acting bronchodilator should be chosen as initial therapy.

There is no evidence that any class of long-acting bronchodilators is superior in reducing symptoms in this group of patients. The choice between drug classes is based on the individual patient's perception of symptom reduction.

For patients with persistent dyspnoea who are on monotherapy, the use of two bronchodilators is recommended.

In patients with severe dyspnea, two bronchodilators may be considered as initial therapy.

If the addition of a second bronchodilator does not improve symptoms, return to monotherapy.

Group B patients are likely to have a comorbidity that may add symptoms, affect prognosis, and require further investigation.

Group C

Initial therapy should consist of bronchodilator monotherapy. In two head-to-head comparisons, MCDD was better at preventing exacerbations than LAAA. Thus, it is recommended to initiate therapy in this group with MCDD.

Patients with persistent exacerbations may benefit from the addition of a second bronchodilator or from a combination of LABA/ICs. Since ICS increase the risk of developing pneumonia in some patients, the combination of LAAA/MCDD is the first choice.

– LABA/MCDD were rated by patients in studies as more effective treatment than monotherapy. If a monobronchodilator is chosen for initial therapy, then MCDD is preferable to LABA for the prevention of exacerbations.

– LAAA/MCDD are more effective at preventing exacerbations than LAAA/ICS, and also have advantages in influencing other endpoints in group D patients.

– Patients in group D have a high risk of developing pneumonia while taking ICS.

In some patients, ICS/LABA may be considered as the first choice. This applies to patients with a history or features suggestive of ACOS. A high level of blood eosinophils can also be considered as a criterion that supports the appointment of ICS, but this issue is under discussion.

In patients with exacerbations despite LABA/MCDD therapy, there are two alternative routes:

– Escalation to LADD/MCDD/XX. A comparison of the effectiveness of exacerbation prevention with LABA/MCDD and LABA/MCDD/ICS is under investigation.

– Switch to BUDD/X. However, there is no evidence that switching from LABA/MCDD to LABA/ICS will lead to better exacerbation prevention. If LABA/ICS therapy has not had a positive effect on symptoms/flare-ups, MCDD may be added.

If a patient continues to experience exacerbations while taking LAAA/MCDD/ICS, consider:

– Addition of roflumilast. Decision can be made in patients with FEV1<50% от должного и хроническим бронхитом, в частности, в случае минимум одной госпитализации в связи с обострением за предшествующий год.

– Addition of a macrolide. Azithromycin has the best of the existing evidence bases. The possibility of developing resistance should also be taken into account when making a decision.

- Cancel ICS. The lack of efficacy, the increased risk of adverse events (including pneumonia), and the evidence base demonstrating their withdrawal without any harm support this recommendation.

As you can see, the new edition of GOLD is quite significantly different from the 2016 version. A large number of new studies, the accumulation of data on the effectiveness of certain treatment regimens in various COPD "squares" gives hope that in the coming years we will be able to talk about complete control over such a disease as COPD.

GOLD‑2017: Global Strategy for the Diagnosis,

Abstract translation from English. Alexandra Merkulova

Thematic issue "Pulmonology, Allergology, Rhino-laryngology" No. 2 (39), May 2017

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