GOLD    2021 update added 244 references, involving management of low- and middle-income countries, COPD      General factors, COVID-19                                                                                                                                                                                                                                 

The key points of update are listed below for your reference

Management of COPD in low- and middle-income countries

In 2018, GOLD held a one-day summit on the epidemiology, clinical characteristics, prevention and control and available resources of COPD in LMIC (low and middle-income countries).

The summit found that there is a lack of epidemiological and clinical characteristics of COPD in low- and middle-income countries. However, the existing data points out that there are huge differences in the management of COPD in these countries. In Lbsp;, ordinary people have a large number of channels to purchase inexpensive tobacco products and are exposed to other exposures (such as household air pollution), which will lead to a significant increase in the risk of COPD progress. However, in these countries, diagnostic lung function tests are not popular, and many people cannot afford effective drug or non-drug treatments.

Therefore, GOLD                                                                                                                                                                                                                                                             

Chapter 1: Definition and Overview

1. Genetic factors

α1                                                                                                                                                                                                                                                              

2. Particle exposure

The relationship between biofuels and COPD still needs further research to be obvious.

Chapter 2: Diagnosis and Initial Assessment

1. Diagnosis

The basic intervention measures recommended by WHO were also included in the diagnostic chapter.

Chapter 3: Prevention and Maintenance Treatment

1. Drug treatment for quitting smoking

4 new chapters have been added to introduce e-cigarettes. As a way to quit smoking, there is still controversy. These 4 chapters mainly introduce the ingredients of e-cigarettes, e-cigarette-related lung damage, possible pathophysiological mechanisms and treatment methods.

2. Vaccines

The Centers for Disease Control (CDC) recommendation was adopted, that for those who were not vaccinated during adolescence, the use of Tdap vaccine (also known as dTaP/dTPa) can prevent whooping cough, tetanus and diphtheria.

3. Drug treatment of COPD in the stable period

The basic intervention measures recommended by WHO were also included in this chapter.

4. Methylxanthine

There is a significant interaction between methylxanthine drugs and commonly used drugs, such as: erythromycin (but not azithromycin), certain quinolones (ciprofloxacin, but not ofloxacin), allopurinol, cimitidine (but not ranitidine), serotonin uptake enzyme inhibitor (fluvoxamine) and 5-lipoxygenase inhibitor ziliutong.

5. Combination of double bronchodilator

EMAX    Study found that compared with long-acting bronchodilator alone, LABA/LAMA       Combination of LABA/LAMA                                                                                                                                                                                                                                  

6. Inhaled hormone (ICS)

By using ICS, both smokers and quit smoking can improve lung function and reduce the rate of acute exacerbation. However, compared with mild smokers and quit smoking, the benefits of current smokers and severe smokers are significantly reduced.

Several studies have evaluated the relationship between ICS treatment and lung cancer risk, but the results are not consistent.

7. Triple therapy (LABA/LAMA/ICS)

A post hoc analysis of patients with severe airflow restriction and acute exacerbation showed that triple inhalation treatment did not significantly reduce mortality compared with treatment without ICS. Two large-scale one-year controlled studies showed that (Ibsp; and ETHOS) showed that for patients with symptomatic episodes of frequent/severe acute exacerbation, fixed-dose inhalation triple treatment could reduce mortality compared to the combination of dual bronchodilator. Most subjects had received triple therapy or related treatment based on LABA/ICS before randomized studies.

8. Mucus dissolving agents and antioxidants

Studies have shown that erdostine can significantly improve whether or not ICS is combined. COPD (mild) acute exacerbation is not clear, and the clear target population of antioxidants can be used in patients with COPD.

9. Other drugs that can reduce acute aggravation

A study of patients with no β-blocker indication and combined with moderate to severe COPD showed that the use of β1 receptor blocker indication metoprolol was not prolonged compared to the placebo group. Compared with the placebo group, the interval between acute exacerbations of these patients was higher in acute exacerbations of these patients. Compared with the placebo group, the rate of acute exacerbations of these patients was higher. There is no evidence that β-blocker indication should be applied to those patients with no cardiovascular indication.

10. Suction device

Pharmacist-led interventions and health guidance from non-professionals can improve inhalation techniques and compliance with patients.

11. Pulmonary Rehabilitation

A study of RCT shows that compared with routine oxygen therapy, giving HFNT during exercise does not improve exercise tolerance time, primary outcome or health. However, using HFNT can significantly improve 6 MWD.

12. Self-management

Added the chapter on self-management

13. Palliative treatment for dyspnea

Acupuncture/acupuncture can improve advanced COPD patients' symptoms of dyspnea and quality of life.

14. Ventilation support

The study found that adding NIV can significantly extend readmission time within 12 months.

Chapter 4: Stability Period COPD Management

1. Exercise

A randomized controlled study of patients with a history of acute aggravation showed that community-based exercise guidance intervention in such patients could not improve emergency medical visits or survival. Another pedometer-based exercise intervention study showed that exercise can reduce the risk of acute aggravation during the follow-up period of 12 months to 15 months.

2. Pulmonary Rehabilitation Plan

The COVID-19 pandemic has led to the need to be revised under the premise of maintaining social distancing. The family-based pulmonary rehabilitation program, through remote monitoring, helps to follow up patients early after discharge and is economical and convenient.

Chapter 5: Management of acute aggravation

1. Research background

The basic intervention measures recommended by WHO are also included in this chapter

2. Antibiotics

Procalcitonin is an acute phase reactant that increases during inflammation and infection. Studies have guided the use of antibiotics by evaluating PCT levels. However, the effectiveness of this biomarker is still controversial.

Several studies (mainly conducted in the outpatient clinic) suggest that PCT’s guidance of antibiotic use can reduce the time and side effects of antibiotic use while ensuring the same clinical efficacy. A review and meta-analysis of hospitalized patients with acute exacerbation of COPD showed that PCT’s use did not significantly reduce total antibiotic use.

A study of patients admitted to ICU due to acute exacerbation of COPD showed that starting or discontinuing antibiotics based on PCT significantly increased mortality compared to standard antibiotic therapy.

Given the conflicting conclusions of these research, it is not recommended to use PCT to decide on the use of antibiotics in acute exacerbations. Further rigorous methodological research is needed to clarify this point.

Chapter 6: COPD and comorbidities

1. Lung cancer

Several epidemiological and observational cohort studies have shown that there is a certain relationship between COPD and lung cancer. The common origin of these two diseases is not only tobacco contact. The genetic susceptibility in patients, DNA methylation changes, local chronic inflammation of the lungs and abnormal lung repair mechanisms are all important potential factors that lead to the development of lung cancer. Whether the severity of airflow limitation is related to the occurrence and development of lung cancer is still controversial. The study found that compared with the degree of airflow limitation, emphysema and lung cancer are more correlated. The study found that those patients diagnosed with emphysema through CT and diagnosed with airflow limitation through lung function have the greatest risk of lung cancer.

Optimal interventions for lung cancer (for COPD): quit smoking/avoid tobacco exposure. Several studies have found that using LDCT screening can significantly improve survival rates among older people, smokers or more recently 15                                                                                                                                                                                                                                    

New Table 6.1 Common Risk Factors for Progress of Lung Cancer:

Age>55    

Smoking history >30     Year of guarantee

Airflow restriction    FEV1/FVC<0.7

BMI<25

A family history of lung cancer

2. Heart failure

For patients with heart failure, β1 receptor blocker treatment is recommended, which can improve survival. Selective β1 receptor blocker indications are limited to use in patients with heart failure. The cardiovascular indications of β1 receptor blocker cannot be used simply to prevent acute exacerbations.

3. Ischemic heart disease (IHD)

For patients with high-risk IHD, COPD, after acute exacerbation, 90 days after acute exacerbation, the risk of cardiovascular events is significantly worsened (death, myocardial infarction, stroke, unstable angina, transient ischemic heart disease). COPD, acute exacerbation hospitalization is closely related to mortality rates of acute myocardial infarction, ischemic stroke and intracranial hemorrhage within 90 days.

4. Cognitive impairment

Cognitive impairment (CI) is very common among patients with COPD. Some studies have pointed out that the average prevalence is 32%. The prevalence and severity vary from study to study. Large-scale neuropsychological studies have shown that 56% of patients with COPD may have combined with CI. Longitudinal studies show that patients with middle-aged diagnoses with COPD are at greater risk of progression to CI.

CI     Can occur in patients with airflow restriction at all levels.

CI    Can cause impairment of daily basic living functions, which is related to impaired health status.

COPD        Combined     CI     The risk of hospitalization increases and the length of hospitalization caused by acute exacerbation.

It is not clear that the impact of CI on patients’ self-management skills on COPD, but current studies have confirmed that CI will affect the use of inhalers.

Chapter 7: COVID-19 and COPD

COPD    The patient has new or aggravated respiratory symptoms, fever and/or other symptoms, even if these symptoms are mild, may be related to COVID-19. Patients should all undergo SARS-CoV-2 infection testing.

COPD     Patients should continue to take oral or inhalation as prescribed COPD                                                                                                               �

When a widespread COVID-19 epidemic occurs in the community, lung function tests are limited to those with urgent need to diagnose COPD patients and/or patients who undergo pulmonary function assessments in order to undergo surgery.

Maintaining social distancing and protection should not lead to isolation from society and not participating in social activities. Patients should keep in touch with their family and friends through various means such as telephone. It should be ensured that the patients have sufficient medication.

Patients should be encouraged to obtain COVID-19-related medical information through reliable channels.

Remote COPD patients follow-up guide and printable follow-up list should be provided. Due to geopolitical relations, our attention to the new crown epidemic in neighboring India continues to be high: on June 18, India added 62,409 new cases throughout the day, with a total of 383,521 deaths.

But unexpectedly, on a global scale, if ranked by the number of new cases, India can only rank second, and Brazil is the "champion". From 0:00 to 24:00 on June 18, Brazil had 85,861 new confirmed cases and 2,760 new deaths. As of that day, Brazil's cumulative number of confirmed cases exceeded 17.7 million, second only to the United States and India, ranking third in the world.

The epidemic in Brazil has continued to this day since 2020, which is worrying. However, it has been constantly exposed to the treatment of new crown and the infection has caused greater anxiety in the academic community.

At the end of 2020,

Rare fungal infections have quietly emerged in Brazil

Recently, researchers from Brazil and the Netherlands published a scientific research briefing in Journal          Fungi, saying that they had paid attention to special infections caused by Candida auris in medical institutions in Brazil.

Candida auricida was first discovered by Japanese doctors in 2009. Since the fungus was originally obtained from the patient's ear part, it is called Candida auricida. Some studies believe that it may have infected humans as early as the 1990s.

Journalof    Fungi reports involved two COVID-19 patients admitted to the hospital for COVID-19 in the same hospital and the same intensive care unit (ICU) in El Salvador, Brazil in December last year. One was a 59-year-old male and the other was a 72-year-old female. Among them, the male patient received glucocorticoid treatment for up to 34 days due to severe respiratory symptoms and kidney damage, and during which he developed multiple infections of Candida auricida, multidrug-resistant Gram-negative bacteria and Enterococcus faecalis. The patient received 17-day empirical antifungal treatment for anilifungin, and the clinician did not treat secondary bacterial infections. He was subsequently discharged from the hospital after the 49th day of admission to the ICU.

In contrast, the elderly woman with chronic renal insufficiency, diabetes and hypertension was not so lucky. The new coronavirus not only brought her severe respiratory distress symptoms, but also caused sepsis. The patient also received anti-infection treatment with meropenem tecolanin while treating glucocorticoids. Subsequent blood culture showed that carbapenem-resistant Acinetobacter baumannii and Candida auriculata were positive. Then, the patient received polymyxin combined with anifenin antifungal treatment.

Although she defeated Candida auris, she lost to the bacteria. In the end, she died in January 2021 from catheter-related blood flow infections caused by carbapenem-resistant Morganella and Klebsiella pneumoniae.

Candida auris is not new,

US FDA has long listed it as a Superbug

At the end of 2019, the Centers for Disease Control and Prevention (FDA) divided pathogenic microbial threats into four levels in the antibiotic resistance threat report, namely urgent threats, serious threats, threats to be paid attention to and surveillance list. Candida auris is located in the list of urgent threats, and conventional disinfectants cannot kill the bacteria.

Some analysts say that the danger of Candida auris lies in drug resistance: strains usually develop resistance to a variety of antifungal drugs including fluconazole, voriconazole, amphotericin B, caspofungin, etc. in a short period of time, so they are called "super fungi".
Chapter completed!