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Conference Coverage

Updates From 2022 GOLD International COPD Conference

Gerard J. Criner, MD
01/12/2023

In this podcast, Gerard J. Criner, MD, provides an overview of the recent revisions made to the GOLD report, including the strategy for the diagnosis, management, and prevention of COPD and issues surrounding COPD guidance that should be updated in the future.

Additional Resource:

Gerard J. Criner, MD, is a professor and Chair of thoracic medicine and surgery at the Lewis Katz School of Medicine at Temple University and Director of Temple Lung Center (Philadelphia, PA).

 

TRANSCRIPTION:

Jessica Bard:

Hello everyone, and welcome to another installment of Podcast360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant360, a multidisciplinary medical information network. The Gold strategy document for the diagnosis, management, and prevention of COPD is updated each year based on a standard scientific review process.

Dr Gerard Criner is here to speak with us today about the recent revisions made to the Gold report. Dr. Criner is a professor and Chair of thoracic medicine and surgery at the Lewis Katz School of Medicine at Temple University and the Director of Temple Lung Center in Philadelphia, Pennsylvania. Thank you for joining us today, Dr Criner. Can you please tell us about the purpose of the 2022 Gold International COPD conference?

Dr Gerard Criner:

Yeah. The Gold 2022 Conference is a series. This is the eighth year that we've done it. It's an international COPD conference where GOLD members participate and highlight the new revisions in the report, and have that meeting in terms of reviewing the sentinel new issues that are discussed in the report, but also use it somewhat as a workshop to talk about topics that may not be really addressed yet in a report but need to be addressed, so that we're always trying to move the field forward in trying to improve the recognition and treatment of patients with COPD.

We hold it annually on world COPD day, again, for that reason to highlight that COPD is an important worldwide disorder that needs to have much more attention than it currently has so we can better improve the care of patients who have the disorder.

Jessica Bard:

Can you please give us an overview of the revisions made to the GOLD Report?

Dr Gerard Criner:

Yeah. There were several revisions in this year's report. One of the things that we first emphasized is really the definition of COPD. We talked about that before. But we really broadened it to really capture that the development of COPD is more than just exposure to cigarette smoke. When you look at it as a global disease, there is many other exposures of inhalants that can contribute to the development of COPD, such as biomass fuel exposure. In many parts of the world, it's a predominant cause of patients developing COPD from an inhalant standpoint. Other things in terms of environmental exposures, which are becoming more of a concern with a planet that's changing rapidly in terms of our air quality as well as the heat exposures that are occurring to everyone right now. And talking about the pesticides and other pollutants that people inspire throughout the US as well as the non-US that may contribute to COPD.

There's also an emphasis on that COPD itself may occur because people are predisposed to it from either genetic factors, or things that happen in terms of lung development throughout one's early stage of your development as a neonate through early childhood and adolescence, because of host vectors that are determined somewhat by your socioeconomic status. And basically, do you have other concurrent respiratory illnesses or are undernourished in some degree and have some other serious respiratory or cardiac diseases that contribute to the development of COPD? So the definition really was expanded, and really identified to capture those illnesses.

We also spend some time talking about the need for a new definition for COPD exacerbations, that patients with COPD can exacerbate their symptoms, but those symptom exacerbations such as dyspnea or chest tightness may be due to another significant comorbid condition, such as a patient with COPD might complain of chest tightness and shortness of breath, and present to the emergency room, but they could have an episode of ischemic heart disease, or heart failure, or a pulmonary embolism that may cause that disorder. And trying to really be more thoughtful in our approach as guidance to clinicians to think of these other entities that could mimic a COPD exacerbation, but really be an important different event than A COPD exacerbation itself in a patient with COPD.

And we talked more about how we need some objective criteria to define the onset of an exacerbation, as well as help grade the severity. And we talk about the importance of maybe using some new, identified physiologic criteria that could help us grade an exacerbation as being mild, or moderate, or severe, that may make it easier for the clinicians to identify a patient who's having more problems and when they need to be hospitalized. So that's something that we spend some time in a report talking about.

We also redefined approach for the initial treatment of COPD in terms of guidance for the pharmacologic regime. There's been more evidence recently that patients who are symptomatic with COPD or have an exacerbation, that perhaps using dual, long-acting bronchodilator therapy may be a better approach than step-wise use of long-acting bronchodilators. And we also give guidance again, about when and how corticosteroids should be used to treat patients to prevent exacerbations. And we simplify the clinical algorithm, instead of a four-quadrant plot, to just be a triad of approach that patients really are classified as grade A when they just have intermittent symptoms, it could be handled with a short-acting bronchodilator. And then patients that are more symptomatic where they would need the use of dual, long-acting bronchodilators. And then patients who have exacerbations either frequent, moderate, or severe, that those patients be treated with an inhaled corticosteroid in addition to long-acting bronchodilators if they have an elevation in peripheral blood eosinophils more than 300, or the use of long-acting bronchodilators if they don't have the increase of exacerbation. So it's really trying to simplify the regime for the clinician to make it easier.

In the report. We also talk more about imaging, specifically CT imaging of the chest, and what that does to help to define patients with COPD. And that we talk about more broadly in terms of what factors can improve mortality in patients with COPD. Historically, we talked about the use of supplemental oxygen in a group of patients, select group, the use of lung volume reduction in surgery. But now we're more expansive in looking at the rule of triple inhaled therapies. That is, two long-acting bronchodilators and inhaled corticosteroid. And more recent studies have shown there are value in select patient populations with COPD in decreasing mortality, as well as again, in a select population, the use of non-invasive ventilation and patients at home.

We also in the report talk about an expanded definition of patients with chronic bronchitis, the pathogenesis of that, the epidemiology of that, the importance of that in affecting patients long-term outcome in terms of exacerbation and mortality. And we also talk about evolving treatments being looked at in that patient population to treat chronic bronchitis.

And we also revise significantly the surgical and interventional treatments for COPD in terms of lung reduction surgery, lung transplantation, and bronchoscopic approaches for lung reduction, as well as those being studied for treatment of patients with frequent exacerbations for chronic bronchitis.

So in a nutshell, quickly, that's the essence of the major revisions that went into the report this year. In terms of the conference, there were four themes that we wanted to address that we think needs to be expanded in the future and are really signals for further development and treatment in COPD from a standpoint of a need for scientific discovery, as well as for us to try to push the field further and try to distill what's in the clinical literature to be able to simplify and improve the treatment of patients with COPD.

One of those was chronic CRO cough with mucus production. We talked about the epidemiology and importance of that. The use that has been described as a potential treatment with using cystic fibrosis transmembrane receptor potentiators for treatment in patients with COPD who have mucus, and the need for further investigation in that area. Then we also talked about interventional treatments for chronic bronchitis and COPD. And that's taken the form of rioplasty, which is pulse field electrical activity, endoscopically, as well as metered dose nitrogen cryospray, and then the use of targeted lung denervation with ablating vagal branches to the bronchial tree that may have an impact on decreasing mucus production as well as exacerbations in patients with COPD.

We also turned our attention to the pulmonary vasculature in patients with COPD, and talked about the incidence and importance of pulmonary hypertension in patients with COPD. How do you detect it? What are the possible treatments that may occur for patients to alleviate pulmonary hypertension? And then talked about the importance of pulmonary emboli that may occur in patients with COPD, and how we can better detect that and potentially treat that.

We also talked about the evolving recognition of interstitial lung capacities in patients with COPD, or interstitial lung disease across the spectrum. And that's reported now in anywhere from 8 to 12% of the patients that undergo evaluation for lung cancer with lung cancer screening. And it's a comorbidity in patients that have COPD, recognized more frequently. And we talked about the detection of that, the importance of that is from a mechanistic standpoint, and also is there a potential role for the antifibrotics that are being currently used in patients with interstitial lung diseases, interstitial pulmonary fibrosis, whether they would have any applicability to the patient population with COPD.

And then we talked about really the inhaled treatment with COPD, specifically, is there a role for biologic therapies in COPD? We reviewed the studies that currently have looked at their use in patients with COPD, the interleukin-5 receptor antagonists, and the subset receptor alpha receptor antagonists, and talked about why they didn't have a beneficial effect to date. And the new studies that are being revisited for use of those agents, and other agents like interleukin-4 and 13 receptor antagonists, as well as interleukin-33 antagonists, and what role they have for patients with COPD from a pathogenic standpoint, and could they be durable signals for treatment.

So that in essence was a quick review of what the report talks about as well as what the meeting reviewed.

Jessica Bard:

We'll have to keep our eye on some of those issues for sure Dr. Criner. Thank you so much. That was a great overview. Was there anything else that you would like to add that you believe we missed?

Dr Gerard Criner:

Well, I think the background is this, is that COPD is not a stagnant area for patients. It shouldn't be approached that it's a chronic disease that there's little we can do. I think this highlights in the 5, 10 minutes we've been talking, that there's a lot of things that we can do. There are a lot of things that have come out in the last 1 to 10 years, and there are a lot of new therapies that are currently being looked at.

We have a lot of work to do, but I think the patients with COPD and the clinicians that treat them, should be aware and help promote that this is a important worldwide clinical problem that causes significant morbidity and mortality. And it takes all of us to put our attention to that area to alleviate patients who have this problem.

Jessica Bard:

Thank you for speaking with me. And thank you for all you do for your patients with COPD. We appreciate your time.

Dr Gerard Criner:

Have a good one. Thank you.

Jessica Bard:

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