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Global Initiative for Chronic Obstructive Lung Disease

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) works with health care professionals and public health officials around the world to raise awareness of Chronic Obstructive Pulmonary Disease (COPD) and to improve prevention and treatment of this lung disease.

The GOLD initiative gives out guidelines for COPD Diagnosis, Management, and Prevention.

GOLD guidelines indicate that spirometry is of the utmost importance in diagnosing COPD.

GOLD Classification for COPD - version 2010

For many years GOLD classification was based only on lung function parameters.

The GOLD expert panel classified COPD into 5 stages, ranging from 0 to 4:

 Stage

 Characteristics

0: At risk

Normal Spirometry
Chronic Symptoms (cough, sputum production)

1: Mild COPD

FEV1/FVC < 70%
FEV1 > or equal to 80% predicted
With or without chronic symptoms (cough, sputum production)

2: Moderate COPD

FEV1/FVC < 70%
FEV1 between 50 and 80% predicted
With or without chronic symptoms (cough, sputum production)

3: Severe COPD

FEV1/FVC < 70%
FEV1 between 30 and 50% predicted
With or without chronic symptoms (cough, sputum production)

4: Very Severe COPD

FEV1/FVC < 70%
FEV1 < or equal to 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

GOLD Classification for COPD - version 2013

In 2013 the GOLD initiative published a new classification for COPD severity. Where the older versions only took lung values in account, GOLD 2013 also takes severity of symptoms and number of exacerbations into account. Aside from the classic GOLD 1, 2, 3 and 4 stages, the new classification distinguishes also stages A, B, C and D.

Symptom severity is assessed using the mMRC scale (modified Medical Research Council Dyspnea scale) or the CAT questionnaire (COPD Assessment Test).

The new GOLD classification is as follows:

GOLD class4CD>1Exacerbation history
3
2AB1
10
mMRC 0-1
CAT <10
mMRC>1
CAT>9
Symptoms

The GOLD classification uses risk factors (GOLD 1 to 4 and number of exacerbations) and symptom severity (mMRC or CAT scale). In case both risk factors would fall in a different category, the highest risk factor is used (eg: GOLD 1 (GOLD A or B) with 2 COPD exacerbations last year (GOLD C or D) would be GOLD C or GOLD D).

GOLD A and B are low risk, GOLD C and D are high risk patients.

GOLD A and C have few symptoms, GOLD B and D have more symptoms.

GOLD Therapy Guidelines

The new GOLD 2013 treatment plan is based on reduction of symptoms and reduction of risks.

patient groupfirst choice treatmentalternative treatmentother possible treatments
SABA = short-acting beta2-agonist
SAAC = short-acting anticholinergic
LABA =long-acting beta2-agonist
LAAC = long-acting anticholinergic
ICS = Inhaled corticosteroid
PDE4I = phosphodiesterase-4 inhibitor
Awhen necessary: SAAC
or
SABA
LAAC
or
LABA
or
SAAC + SABA
Theophylline
BLAAC
or
LABA
LAAC + LABA SABA and/or SAAC

Theophylline
CICS + LAAC
or
LABA
LAAC + LABA
or
LAAC + PDE4I
or
LABA + PDE4I
SABA and/or SAAC

Theophylline
DICS + LAAC
and/or
LABA
ICS + LABA + LAAC
or
ICS + LABA + PDE4I
or
LAAC + LABA
or
LAAC + PDE4I
carbocysteine

SABA and/or SAAC

Theophylline

The below graph was the GOLD treatment plan in GOLD 2010 and is for reference only:

gold therapy

The official guidelines can be downloaded from the GOLD website

Fletcher Graph

Many patients believe that once damage has been done, smoking cessation isn't necessary anymore.
The Fletcher-Peto graph clearly shows the importance of quiting smoking, even if serious damage is already present.

fletcher-peto graph
Fletcher's graph clearly shows the importance of smoking cessation, even in late stage COPD