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Keywords:

  • comorbidities ;
  • COPD ;
  • diagnosis ;
  • exacerbations ;
  • spirometry

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Basic aspects of GOLD
  5. The 2011 revision
  6. GOLD and the future
  7. References

Introduction

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has published a strategy for diagnosis and for management of chronic obstructive pulmonary disease (COPD) since 2001 and this has formed the basis for numerous national and regional guidelines.

Objectives

We describe the background for the 2011 revision of the GOLD document.

Methods

The GOLD document is updated annually and revised every 5 years based on published research as well as an evaluation by an expert panel of how to best formulate and disseminate knowledge on COPD.

Results

The GOLD 2011 revision states that spirometry is required for making a clinical diagnosis of COPD. At the same time, the document has less emphasis on spirometric evaluation of disease severity and launches a combined assessment taking symptoms, spirometry and history of exacerbations into account. This is matched with initial treatment for COPD where smoking cessation, pulmonary rehabilitation and physical activity in general are given high priority followed by pharmacologic treatment guided by the novel assessment scheme. Comorbidities are often present in COPD and the GOLD 2011 revision gives some guidance in how to manage these as well as how to manage COPD in the presence of comorbidities.

Conclusion

A more clinically oriented GOLD document will hopefully improve assessment and management of COPD.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Basic aspects of GOLD
  5. The 2011 revision
  6. GOLD and the future
  7. References

Chronic obstructive pulmonary disease (COPD) is a major health problem with increasing morbidity and mortality; in 2020, COPD will be the 3rd leading cause of mortality worldwide and the 5th leading source in terms of burden of disease [1]. The main reasons for the increase are ageing, increase in risk factors globally, including smoking, and better treatment of other major disease, such as cardiovascular disease in our part of the world and communicable diseases globally. Although COPD has received increasing attention from the medical community in the Nordic countries in recent years, we only need to go 10–15 years back in time to reach a point in time when COPD was associated with both diagnostic and therapeutic nihilism.

In 1998, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was formed in a collaboration between Claude Lenfant and Suzanne Hurd from the US National Heart, Lung and Blood Institute and prominent COPD physicians, not least Professor Romain Pauwels. The aim was to bring more attention to the management and the prevention of COPD. In 2001, the GOLD programme released a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD [2]. This document inspired and formed the basis for numerous clinical COPD guidelines all over the world.

The GOLD Strategy document is updated annually, and from the outset, a revision every 5 years was planned. The document was revised in 2006 [3] and in 2011. This review will provide some background on the GOLD initiative and describe the main changes in the 2011 revision and some of the thoughts leading to this revised version.

Basic aspects of GOLD

  1. Top of page
  2. Abstract
  3. Introduction
  4. Basic aspects of GOLD
  5. The 2011 revision
  6. GOLD and the future
  7. References

First, it is important to realize that GOLD is not a clinical guideline and should not be read as such. From the beginning, the idea behind the GOLD document was to provide a strategy for the diagnosis and the management of COPD. This resulted in a global strategy document, and for this reason alone, the GOLD document cannot be regarded a clinical guideline. It is impossible to make the same guidelines for developing countries as for developed countries. If used to inspire guidelines in the Nordic countries, it can and probably should be expanded.

GOLD is a non-governmental organization registered with the US tax office as a not-for-profit organization. It has a formal structure set-up through its by-laws with a Board of Directors, a Scientific Committee and two employees – Executive Director Dr Claude Lenfant and Science Director Dr Suzanne Hurd. The Board of Directors meets face-to-face once annually, whereas the Scientific Committee meets at the annual meetings of the American Thoracic Society and the European Respiratory Society. The GOLD Strategy document is updated annually and revised every 5 years by the Scientific Committee. The committee consists of 10–15 members, and the composition of the committee and the conflicts of interest statements of the committee members can be found on http://www.goldcopd.org. Besides the two annual face-to-face meetings, a writing group met several times in 2010–2011 for the preparation of the 2011 revision. Annual updates are published on the GOLD website without having been reviewed externally. In contrast, the 2011 GOLD revision was sent to 27 external expert reviewers, all named in the final report. An executive summary has been published in the American Journal of Respiratory and Critical Care Medicine [4].

The 2011 revision

  1. Top of page
  2. Abstract
  3. Introduction
  4. Basic aspects of GOLD
  5. The 2011 revision
  6. GOLD and the future
  7. References

The aim of the 2011 revision has been to make a shorter, clearer and more easily usable document. With an increasing number of excellent COPD textbooks available, we found that we could cut down on some of the background information on e.g. epidemiology and pathophysiology.

In addition, we had the aspiration of making the document easier to read for a clinician, especially when it comes to relating the document contents to the everyday practice of a clinician. Reports have documented that clinicians do not follow COPD guidelines [5]. The explanation for this is not necessarily that clinicians are not clever enough, but rather that contents of guidelines may not match clinical work in real life. We therefore wanted to propose a linked assessment and management scheme that would mirror the clinical situation better than the previous strategy that was seen to rely almost entirely on level of lung function.

Definition and diagnosis

The definition has not changed substantially. It now reads ‘Chronic Obstructive Pulmonary Disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients’. Focus is now more back to lungs and to airways than it was in the previous document.

Diagnosis of COPD has not changed in the 2011 revision. GOLD still only works with a clinical diagnosis and still maintains that a post-bronchodilator ratio of forced expiratory volume in 1 s (FEV1) over forced vital capacity < 0.70 is suitable as a diagnostic criterion for airflow limitation in the clinical setting [6-8]. GOLD does not endorse screening for COPD but strongly encourages early detection through active case-finding or ‘opportunistic screening’ as this has been shown to result in an impressive yield of approximately 30% in a Danish general practice setting [9]. We acknowledge that there is a risk of underdiagnosis in young adults and potentially a risk of over-diagnosis in the elderly but do not think that shifting to use of lower limit of normal will solve all issues around a clinical diagnosis of COPD [8]. In the epidemiological setting, GOLD diagnostic criteria cannot directly be applied to epidemiology where airflow limitation is often used as a proxy for COPD [10].

Importantly, spirometry is no longer recommended to support a diagnosis of COPD. Instead, spirometry is required for making a diagnosis of COPD. It is well known that spirometry is often not part of the diagnostic pathway for COPD, and in many parts of the world, spirometry is not feasible for economic reasons. Misdiagnosis is frequent in patients diagnosed on symptom history alone and it is the opinion of GOLD that the use of spirometry can only be properly promoted if it is deemed necessary and not just helpful.

Assessment of COPD

This is the area in which the most profound changes have been made. When reading the previous version of the GOLD document, it is clear that symptoms matter. However, the notion of the previous document was that level of FEV1 was decisive for assessing severity and treatment. When the ‘COPD pyramid’ based on the previous GOLD stages was suggested in 2001, there was little evidence to support this and an assessment scheme will only rarely be evidence based as few studies so far have tested different diagnostic criteria or modalities of assessment.

The revised document recommends assessment of symptoms, lung function, risk of exacerbations and comorbidities as shown in Table 1.

Table 1. Assessment of chronic obstructive pulmonary disease (COPD)
  1. GOLD, Global Initiative for Chronic Obstructive Lung Disease; mMRC, modified Medical Research Council scale for breathlessness; FEV1, forced expiratory volume in 1 s; CVD, cardiovascular disease.

Assess symptoms
GOLD recommends the use of the mMRC breathlessness scale or the COPD Assessment test
Assess degree of airflow limitation
GOLD recommends using spirometry and using four grades split at 80%, 50% and 30% of predicted value.
Assess risk of exacerbations
GOLD recommends using history of exacerbations and spirometry. Two exacerbations or more within the last year or an FEV1 < 50% of predicted value is an indicator of high risk.
Assess comorbidities
Assess comorbidities and treat them appropriately. The most frequent comorbidities are CVD, depression and osteoporosis.

A systematic assessment of COPD is necessary to ensure sufficient quality in the management of COPD. Regarding symptoms, GOLD suggests the modified Medical Research Council (mMRC) or COPD Assessment test scales but other symptom scales can be used; e.g. the Clinical COPD Questionnaire. The crucial aspect is to consider whether the patient has only trivial symptoms or feels significantly limited by them. Subsequent GOLD updates may include other scales and the recommendation can be altered for regional/national guidelines if other scales are better suited locally.

For risk of exacerbations, a history of two or more exacerbations per year indicates a high likelihood of future exacerbations, the cut-off being well supported [11, 12]. Because of the impact of an exacerbation leading to hospital admission [13, 14], one severe exacerbation requiring hospitalization will also indicate high risk.

The first three items in the assessment can be combined as illustrated in Fig. 1.

figure

Figure 1. Combined assessment of chronic obstructive pulmonary disease. Printed with permission from Global Initiative for Chronic Obstructive Lung Disease (GOLD). CAT, COPD Assessment test; mMRC, modified Medical Research Council scale for breathlessness.

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The practical use of this is shown in Fig. 2. First, assess symptoms; next, assess risk of exacerbations.

figure

Figure 2. (A) First step in the combined assessment of chronic obstructive pulmonary disease (COPD). (B) Second step in the combined assessment of COPD. Modified with permission from Global Initiative for Chronic Obstructive Lung Disease (GOLD). CAT, COPD Assessment test; mMRC, modified Medical Research Council scale for breathlessness; FEV1, forced expiratory volume in 1 s.

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This assessment does not include comorbidities. However, studies have shown that the prevalence of comorbidities is relatively independent of grade of airflow limitation and assessment of comorbidities should be done for all patients. However, it is likely that patients with many symptoms (B and D) will more frequently have comorbidities resulting in breathlessness, not least asthma and/or heart failure.

Management of stable COPD

Management should follow the patient categorization. In contrast to the assessment scheme, management recommendations need to be evidence based. Smoking cessation is strongly recommended for all smoking COPD patients and will typically include both non-pharmacological and pharmacological treatment.

The most important among the recommended non-pharmacological treatments relate to physical training and physical activity. All COPD patients with breathlessness when walking at their own pace on level ground benefit from rehabilitation and from maintenance of physical activity, improving their exercise tolerance and quality of life, and reducing symptoms of dyspnoea and fatigue. In addition, rehabilitation shortly after an exacerbation has also been shown to be highly efficacious [15]. However, physical activity in general should also be strongly promoted. There is no reason to believe that the beneficial effects of physical activity seen in the general population should not apply to COPD patients – on the contrary, physical activity is essential to avoid deconditioning, to improve breathlessness and to reduce risk of comorbidities. In short, the value of pulmonary rehabilitation and of physical activity cannot be overestimated.

The recommendations for pharmacological treatment will mainly relate to choice of initial therapy. To date, there is a clear lack of trials informing us on treatment choices in case of lack of efficacy on first choice treatment; in the GOLD scheme, ‘First choice’ therapy is to be seen as initial therapy, whereas ‘Second choice’ treatments can be considered in patients not sufficiently managed on initial therapy. It should also be remembered that evidence-based recommendations are often based on group comparisons from randomized controlled trials and that in the clinical reality, a significant proportion of patients will often do well on a treatment that may be slightly less efficacious in a large trial. The GOLD first and second choice treatments are shown in Fig. 3.

figure

Figure 3. (A) First choice medications for the initial treatment of stable chronic obstructive pulmonary disease (COPD). (B) Other medications for use in the treatment of stable COPD. Modified with permission from Global Initiative for Chronic Obstructive Lung Disease (GOLD). mMRC, modified Medical Research Council scale for breathlessness; CAT, COPD Assessment test; SABA, short-acting beta-agonist; SAMA, short-acting antimuscarinic agent; ICS, inhaled corticosteroid; LABA, long-acting beta-agonist; LAMA, long-acting antimuscarinic agent; PDE4-inh, phosphodiesterase4-inhibitor.

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Follow up and re-evaluation is an important part of management of any chronic disease and therefore also for COPD. There is little evidence to inform about interval needed for second and for subsequent assessments. GOLD suggests regular follow up to evaluate effects of initiated treatments, including smoking cessation where needed, and non-pharmacological as well as pharmacological treatment. The assessment suggested in Table 1 and Fig. 1 can also be used for follow up. For adjustment of management, however, it must be considered if improvement in a patient is associated with treatments; as an example, it would be foolish to stop treatment with a long-acting bronchodilator in a patient who as a response to treatment had moved from an mMRC score of 3 to a score of 2.

Management of exacerbations

We have introduced a new chapter on exacerbations. The GOLD definition of an exacerbation is ‘An exacerbation of COPD is an acute event characterized by a worsening of the patient's respiratory symptoms that is beyond normal day-today variations and leads to a change in medication’. The chapter deals with assessments and treatment of exacerbations that are seen as key events in the course of COPD [11-14, 16]. Treatment with bronchodilators, systemic corticosteroids and antibiotics is presumably not controversial. More important are the recommendations on supplemental oxygen therapy and non-invasive mechanical ventilation (NIV). Regarding oxygen treatment, emphasis is on pulse oximetry for tracking and/or adjusting oxygen therapy as controlled oxygen should be titrated to improve the patient's hypoxaemia with a target saturation of 88%–92% [17]. Once oxygen is started, arterial blood gases should be checked 30–60 min later to ensure satisfactory oxygenation without carbon dioxide retention or acidosis. NIV has been studied in many randomized controlled trials in acute respiratory failure, consistently showing significant benefits on survival, risk of intubation and complications because of mechanical ventilation [18]. Over the last 10 years, the indications for NIV seems to have shifted towards more severe patients, and in all but a few situations, there is nothing to be lost by a trial of NIV. Nonetheless, the indication of NIV for chronic hypercapnic failure is far from being elucidated.

Comorbidities in COPD

COPD often coexists with other diseases, comorbidities [19], and patients with complex comorbidities are growing in numbers. In COPD, comorbidities may have a significant impact on prognosis [20, 21]. The revised GOLD document has for these reasons included a new chapter giving simple advice to the clinician managing patients with COPD and comorbidities. Cardiovascular diseases are major comorbidities in COPD and probably both the most frequent and the most important diseases coexisting with COPD [20-22]. Differential diagnosis may be difficult because comorbidities may mimic COPD symptoms. Osteoporosis, metabolic syndrome and anxiety/depression are also major comorbidities in COPD [22-24]. These diseases – all treatable – are often underdiagnosed, and they impact on both health status and prognosis. Lung cancer is frequently seen in patients with COPD and is the most frequent cause of death in patients with mild COPD.

In general, the presence of comorbidities should not alter COPD treatment, and comorbidities should be treated as if the patient did not have COPD. The latter is particularly true in heart failure where having COPD is a significant risk factor for insufficient use of beta-blockers [25]. Cardio-selective beta-blockers are not contraindicated in COPD [26] as the benefits of selective beta1-blockers are considerably larger than any potential risk associated with treatment, even in patients with severe COPD. Moreover, beta-blockers may reduce overall mortality and COPD exacerbations when added to established therapy for COPD, independently of overt cardiovascular disease and cardiac medication, and without adverse effects on lung function [27].

GOLD and the future

  1. Top of page
  2. Abstract
  3. Introduction
  4. Basic aspects of GOLD
  5. The 2011 revision
  6. GOLD and the future
  7. References

The GOLD Strategy document is a living document and will continue as such. The strategy for annual updating and revising the document every 5 years will continue with future increasing use of the Web, more translation into major languages, and in the near future, a venture into the world of Apps.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Basic aspects of GOLD
  5. The 2011 revision
  6. GOLD and the future
  7. References
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