Gold Guidelines

Chronic obstructive pulmonary disease (COPD) is an umbrella term that encompasses a variety of progressively debilitating lung diseases, such as emphysema and chronic bronchitis.

Despite great efforts by health professionals worldwide to raise awareness about the dangers of cigarette smoking, the number of people who have COPD remains widespread. The disease is expected to rank as the world’s fifth-largest killer by 2020. In the United States, COPD is already the nation’s third-leading killer, and those figures are expected to keep rising. As many as 24 million American men and women are currently affected by COPD, yet only half of them are aware of the disease and its consequences.

Formation of the Global Initiative for COPD (GOLD)

A global commission was formed in 1998 to educate and help set universal standards of treatment, to help stem the tide of increasing COPD cases, and to help those who have the disease understand it. By 2001, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) filed its first report, which has since been revised several times. GOLD’s most recent 2012 publication outlines a more individualized approach to COPD classification and treatment.

Dr. Roberto Rodriguez-Roisin, Chair of the GOLD Board of Directors, and Dr. Jørgen Vestbo, Chair of the GOLD Science Committee, explained that COPD patients shouldn’t be evaluated only by spirometry lung function tests, as consideration of a variety of factors, such as a patient’s day-to-day symptoms, can lead to a more accurate COPD diagnosis.

“Spirometry is essential for diagnosis of COPD, but it doesn’t fully capture the impact of the disease on individual patients,” explained Dr. Vestbo. The newest GOLD guidelines are therefore meant to draw attention to other factors that affect COPD patients, such as the severity of their shortness of breath and the frequency of their flare-ups or exacerbations.  COPD patients need to pay close attention to reducing flare-ups, which are typically caused by bacterial or viral infections. Multiple, frequent exacerbations may cause a permanent loss of lung function and further worsen the disease.   

Revised GOLD Guidelines

As previously mentioned, the 2012 GOLD guidelines for COPD consider a multitude of factors besides breathing tests to determine overall lung function. In addition, the GOLD treatment strategy is additive, which means that new medications are added but not subtracted as the disease progresses. The new guidelines also classify COPD in four stages according to its severity.

COPD Stage I/Mild

Stage I COPD is considered mild and has few symptoms. Coughing is infrequent and lung function tests reveal forced expiratory volume (FEV1) numbers at less than 80 percent of normal lung function (FEV1/FVC<80%). Treatment for Stage I COPD is usually a short-acting bronchodilator to be used as needed to open up restricted airways.      

COPD Stage II/Moderate

Stage II COPD is considered moderate and you may experience shortness of breath while exercising. As in Stage I, treatment for Stage II COPD can be both a short-acting bronchodilator to be used as needed and one or more long-acting bronchodilator medications. Patients with moderate COPD are also urged to exercise their lungs by keeping active and undergoing pulmonary rehabilitation to maintain lung function. Stage II FEV1 numbers reveal between 79 and 50 percent of normal lung function (FEV1/FVC<79-50%).   

COPD Stage III/Severe

Stage III COPD patients typically have increased shortness of breath. In addition to treating Stage III COPD with one or more bronchodilators and pulmonary rehabilitation, physicians will often add inhaled corticosteroids for periods of exacerbation. Stage III COPD patients should be vaccinated for pneumonia and seasonal influenza. Stage III FEV1numbers reveal between 49 and 30 percent of normal lung function (FEV1/FVC<49-30%).         

COPD Stage IV/Very Severe

Stage IV COPD is the most serious stage of the disease. Symptoms worsen, coughing and mucus production are more frequent, and any activity is a challenge. Stage IV COPD sufferers often rely on oxygen therapy, but flare-ups from the disease are increasingly serious, even deadly. In addition to a variety of bronchodilators and inhaled corticosteroids, oxygen therapy, vaccinations and antibiotics, treatment may also include surgery to remove damaged lung tissue. Stage IV FEV1 numbers reveal less than 30 percent of normal lung function (FEV1/FVC<30%).      

The GOLD guidelines are only meant to help physicians develop universal standards in diagnosis and treatment. In general, COPD is a very complex disease. Other factors can also both positively and adversely affect lung function, such as if a person:

  • is overweight or obese
  • has other co-morbidities like heart disease and high blood pressure
  • hasn’t quit smoking
  • has a history of immobility