Classification of Chronic Obstructive Pulmonary Disease (COPD) according to the new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: Comparison with GOLD 2011

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality worldwide. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) project has been working to improve awareness, prevention and management of this disease. The aim of this study is to evaluate how COPD patients are reclassified by the 2017 GOLD system (versus GOLD 2011), to calculate the level of agreement between these two classifications in allocation to categories and to compare the performance of each classification to predict future exacerbations. Two-hundred COPD patients (>40 years, post bronchodilator forced expiratory volume in one second/forced vital capacity<0.7) followed in pulmonology consultation were recruited into this prospective multicentric study. Approximately half of the patients classified as GOLD D [2011] changed to GOLD B [2017]. The extent of agreement between GOLD 2011 and GOLD 2017 was moderate (Cohen's Kappa = 0.511; p < 0.001) and the ability to predict exacerbations was similar (69.7% and 67.6%, respectively). GOLD B [2017] exacerbated 17% more than GOLD B [2011] and had a lower percent predicted post bronchodilator forced expiratory volume in one second (FEV1). GOLD B [2017] turned to be the predominant category, more heterogeneous and with a higher risk of exacerbation versus GOLD B [2011]. Physicians should be cautious in assessing the GOLD B [2017] patients. The assessment of patients should always be personalized. More studies are needed to evaluate the impact of the 2017 reclassification in predicting outcomes such as future exacerbations and mortality.     

Global Initiative for Chronic Obstructive Lung Disease strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: an Asia-Pacific perspective

Abstract:   Chronic obstructive pulmonary disease (COPD) is a major public health problem and its prevalence and mortality are increasing throughout the world, including the Asia–Pacific region. To arrest these worldwide trends, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Expert Panel's global strategy for the diagnosis, management, and prevention of COPD was published in 2001. Based on recently published clinical trials, the GOLD statement was updated in 2003. The Asia–Pacific COPD Roundtable Group, a taskforce of expert respirologists from the Asia–Pacific region, has recently formulated a consensus statement on implementation of the GOLD strategy for COPD in the Asia–Pacific region. The key issues identified by the COPD Roundtable Group for comment are: (i) where there is no access to spirometry, diagnosis of COPD could be suspected on the basis of history, symptoms and physical signs; (ii) inhaled bronchodilators are the preferred regular treatment for COPD in the region, but oral bronchodilators may be considered if the cost of inhaled bronchodilators is a barrier to treatment; (iii) the use of an Metered Dose Inhaler with spacer in place of a nebulizer is recommended in the treatment of acute airflow obstruction in patients with COPD; (iv) influenza vaccination is recommended for all patients with COPD in communities where there is a high likelihood of Severe Acute Respitory Syndrome; and (v) simplified pulmonary rehabilitation programmes should be established in areas where comprehensive programmes are unavailable. Physical exercise training and education on smoking cessation should be core elements of any rehabilitation program. In summary, the COPD Roundtable Group supports implementation of the GOLD strategy for the diagnosis, management and prevention of COPD in the Asia–Pacific region, subject to the additions and modifications to the guidelines suggested above.     

Clinical characteristics of patients with chronic obstructive pulmonary disease assessed using GOLD 2016 and GOLD 2018 classifications: a cross-sectional study in China

BackgroundIn 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) removed spirometry as a criterion for classifying GOLD risk groups (A–D, low–high risk).MethodsIn this cross-sectional observational study in China, we used the GOLD 2016 (spirometry included) and 2018 (spirometry eliminated) criteria for classifying GOLD risk groups to describe: the proportion of patients with chronic obstructive pulmonary disease (COPD) in each GOLD risk group; disease severity; demographics and comorbidities. Patients aged ≥40 years with a clinical COPD diagnosis for ≥1 year were included. During a single study visit, patients completed the COPD assessment test, modified Medical Research Council (mMRC) dyspnea scale assessment, and spirometry tests. Demographics, medical history, and treatment data were recorded.ResultsIn total, 838 patients were included. Most patients were male (86.4%), ≥65 years old (58.6%), and current or former smokers (78.5%). By GOLD 2016, the highest proportion of patients were Group D (42.8%), followed by B (28.2%). By GOLD 2018, the highest proportion of patients were Group B (57.3%), followed by A (25.5%). A total of 296 patients (35.3%) were reclassified, either from Group C to Group A or from Group D to Group B. Overall, 36.2% of patients were receiving treatment concordant with GOLD 2016 recommendations; 34.1% were not receiving any inhaled medication.ConclusionsThe distribution of COPD severity shifted from a high-risk category (by GOLD 2016) to a low-risk category (by GOLD 2018). The high proportion of patients not receiving maintenance medication reflects a high level of under-treatment of the disease.     

Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) was developed recently to unify international efforts in the management of the disease. The most important GOLD objective is raising awareness that chronic obstructive pulmonary disease is an increasing health problem. The first step in the GOLD program was to prepare a consensus report, named "Global Strategy for the Diagnosis, Management, and Prevention of COPD," based on best-validated evidence and current pathogenetic and clinical knowledge. It encourages implementation of effective strategies for prevention, diagnosis, and management of the disease in all countries, and emphasizes the importance of renewed research initiatives.     

Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD) in a Primary Care Clinic

ABSTRACT

Chronic Obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality in the United States and internationally. The purpose of this study was to describe spirometry use in the diagnosis of COPD and to evaluate the management of COPD occurring in a primary care clinic. Methods: Two hundred patients with a diagnosis of COPD attending a university-based family medicine clinic were randomly chosen for a retrospective medical record review. Pulmonary function testing, provision of smoking cessation advice and pharmacological management were compared to the recommendations of the Global Initiative for Chronic Obstructive Lung Disease. Results: Mean age was 65.4 years, 48% were male and 72% were Caucasian. Overall, 58.5% (n = 117) of patients had pulmonary function testing, with 60.7% acknowledged in the outpatient record; 55% (n = 110) were receiving medications in combinations that are recommended; and 40% of patients were receiving stage appropriate medications. 67.8% of current smokers were offered smoking cessation advice or treatment. Conclusions: Overall there was low use of recommended medication combinations and stage appropriate treatment, with better observance of diagnostic and risk factor reduction guidelines. In order to improve COPD care for patients, physicians need education about the recommended stepwise treatment options and office systems that promote integration of pulmonary function testing findings into care.     

Reanalysis of the Japanese experience using the combined COPD assessment of the 2011 GOLD classification

BackgroundThe Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 consensus report proposed a new classification system, incorporating symptoms with future risk, in subjects with chronic obstructive pulmonary disease (COPD). We hypothesized it could be applied to Japanese COPD patients.MethodsWe previously analyzed clinical factors related to 5-year mortality in 150 male outpatients with COPD. We reviewed the data and reanalyzed the relationships between the new GOLD classification and various outcomes including mortality.ResultsThere were 51 (34.0%), 12 (8.0%), 57 (38.0%), and 30 (20.0%) patients in GOLD A (forced expiratory volume in 1 s [FEV₁]≥50% predicted and modified Medical Research Council [mMRC] 0–1), GOLD B (FEV₁≥50% predicted and mMRC≥2), GOLD C (FEV₁<50% predicted and mMRC 0–1), and GOLD D (FEV₁ <50% predicted and mMRC≥2), respectively. The GOLD 2011 classification correlated significantly with exercise capacity and multi-dimensional disease staging. Cox proportional hazards analysis revealed that, among several methods categorizing symptoms, the GOLD A-D classification was significantly associated with mortality (p=0.0055).ConclusionAlthough the relative number of patients in each category of the combined COPD assessment classification depended on the choice of symptom measures, the categories defined by the mMRC scale (score 0–1 versus ≥2) were most useful for future risk assessed as mortality. GOLD A had the lowest mortality, followed by GOLD B and C, and D had the highest mortality. Exercise capacity was also stratified by the new GOLD classification.     

A Simplified Screening Questionnaire for Detecting Severe OSA in Chronic Obstructive Airway Disease in Asian Population

Abstract

The aim of this study was to develop a simplified screening questionnaire to detect the existence of severe obstructive sleep apnea (OSA) in chronic obstructive pulmonary disease (COPD) patients to reduce mortality and hospitalization rates. Seventy-seven stable Asian COPD patients aged 69.2?±?11.5?years were retrospectively analyzed into the development group. The simplified screening questionnaire was developed from factors identified from sleep surveys and demographic data to predict severe OSA. Receiver operating characteristic (ROC) curve analysis was used to validate the simplified screening questionnaire. Data from another 78 stable COPD patients were used for validation. The apnea-hypopnea index was similar between the development and validation groups (26.3?±?21.9 and 27.6?±?21.1, respectively). After logistic regression analysis in the development group, snoring, body mass index ≥27.5?kg/m², witnessed apnea and coronary artery disease were incorporated into the screening questionnaire to predict OSA. When this questionnaire was applied to the validation group, the results were similar. The simplified screening questionnaire developed is useful in identifying severe OSA in COPD patients.     

GOLD2011对稳定期COPD患者病情评估和治疗选择的影响

目的探讨2011年慢性阻塞性肺疾病全球倡议（GOLD）对COPD稳定期患者疾病评估和治疗带来的变化和影响。方法将269例COPD患者进行了症状、肺功能、急性加重情况的记录,并根据2006及2011GOLD策略进行了分期和分组的分析,比较新旧策略对患者治疗选择的影响。结果用CAT评估与mMRC评估比较,增加了症状较多组（B和D）的患者例数,两个评估方法中C和D组患者总数相仿。对比2006及2011GOLD策略,GOLD2006中Ⅱ级患者在GOLD2011中分组变化尤为突出;新分组导致中度COPD患者中的44例（16．4％）需要改变初始治疗,急性加重的风险评估是影响分组及治疗选择的最主要的因素,FEV1与临床症状和AECOPD频率虽有相关性（P〈0．01）,但FEV1并不是评估COPD病情的敏感指标。结论2011GOLD策略对COPD稳定期患者的评估更加全面,但在临床操作上略显复杂,而且主要影响了中度COPD患者的分组及治疗选择的改变,AECOPD频率对COPD风险分级的影响非常大。     

Global Initiative for Chronic Obstructive Lung Diseases (GOLD)

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of chronic morbidity and mortality throughout the world. In an effort to increase awareness of COPD and to develop consensus on scientific evidence for management and prevention of this disease, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) program was formed. A summary of the GOLD program is presented along with information about GOLD documents.     

Breathlessness or Health Status in Chronic Obstructive Pulmonary Disease: The Impact of Different Definitions

Objective: The GOLD 2011 report recommends the use of symptoms, exacerbation history, and FEV1% predicted to categorise patients into groups A–D. We investigated the choice of mMRC or CAT on category assignment and characterization of the categories. Methods: Patients were prospectively recruited from tertiary hospitals in China, as part of the INTACT study, with a prior diagnosis of COPD. The GOLD categories were defined using mMRC and CAT, along with exacerbations in the previous year, and FEV1% predicted. Results: 1,465 patients were included. The most prevalent group was group D. However, proportions of patients categorised into groups A to D differed depending on symptom instruments. The use of CAT resulted in more patients being placed into groups B and D. Cardiac co-morbid conditions, particularly ischaemic heart disease, heart failure, and arrhythmia were highly prevalent in groups B and D. Group B appeared to have a similar burden of cardiac co-morbidities to group D, in spite of a higher FEV1 level. Although mMRC assigned a smaller proportion of patients to groups B and D, the patients it did assign had a higher burden of cardiac co-morbidities than patients assigned by CAT. When patients were assessed according to LLN, 14.2% had normal airflow according to ECSC 1993 equations, with 12.6% having normal airflow according to GLI 2012 formulae. Conclusions: The choice of symptom assessment is one potential confounder impacting the patient assignment. Breathlessness may be an important marker of overall disease severity, indicating the presence of cardiac co-morbidities in the GOLD categories.     

Global Strategy for the Diagnosis,Management and Prevention of Chronic Obstructive Lung Disease 2017 Report

This Executive Summary of the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: (i) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; (ii) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; (iii) the concept of de‐escalation of therapy is introduced in the treatment assessment scheme; (iv)non‐pharmacological therapies are comprehensively presented and (v) the importance of co‐morbid conditions in managing COPD is reviewed.     

噻托溴胺对慢性阻塞性肺疾病稳定期患者生存质量的评价

目的观察中度慢性阻塞性肺疾病(COPD)稳定期吸入噻托溴胺的临床疗效。方法将40例中度COPD(Ⅱ～Ⅲ级)稳定期患者随机分为2组,治疗组(噻托溴铵组)(n=20,思力华,Boehinger Ingelheim,18ug,1次/d,早晨给药)和对照组(n=20,按需使用短效抗胆碱能支气管扩张剂),整个观察期为1年,观察2组用药3个月、6个月和1年后肺功能的变化以及StGeorge′s呼吸问卷(SGRQ)等情况,通过6min步行试验(6MWT)观察运动耐力的变化以及随访3～12个月急性加重的例次及住院例次。结果用药3个月后治疗组FEV1、FVC、FEV1/FVC及FEV1占预计值(%)比对照组明显改善,2组比较差异有显著性(P0.05),治疗组运动耐力(6MWT)增加,SGRQ评分比较治疗组明显下降,随访3～12个月治疗组急性加重例次明显减少,与对照组比较差异有显著性(P0.05);治疗组用药后3个月、6个月和1年后肺功能比较无显著差异(P0.05)。结论吸入噻托溴胺可以改善稳定期(Ⅱ～Ⅲ级)COPD患者肺功能与运动耐力,减少急性加重的发作,改善生活质量,不良反应少,使用方便,值得临床广泛推广。     

The Burden of Obstructive Lung Disease Initiative (BOLD): Rationale and Design

Quantifying COPD prevalence worldwide is needed to document COPD's effect on disability, health care costs, and impaired quality of life and to inform governments and health planners. As an adjunct to data obtained from population-based studies, and for countries where a fully powered prevalence survey cannot be done, modeling of COPD prevalence and its economic burdens can help estimate potential health care needs and costs. For comparability, standardized methods for prevalence surveys are needed that can be used in countries at all levels of economic development. The Burden of Obstructive Lung Disease (BOLD) Initiative has developed a set of methods for estimating COPD prevalence and a model for assessing its economic impact, and piloted these methods in China and Turkey. The methods were revised to reflect the findings in the pilot studies, and BOLD is now making the standardized methods available worldwide. The BOLD Operations Center provides training, materials, quality control, and data analysis. BOLD emphasizes data quality control at every stage of the process. Data from paper forms completed in the field are entered electronically to a specially designed secure Web platform. Pre- and post-bronchodilator spirometry testing is done on all participants, and all spirometry data are reviewed for quality. Questionnaires are used to obtain information about respiratory symptoms, health status, exposure to risk factors, and economic data about the burden of COPD. BOLD's standardized methods will provide a uniform way to compare COPD burden within and between countries, and where differences are found, to explore explanations for these differences.     

Rationale and design of the Early Chronic Obstructive Pulmonary Disease (ECOPD) study in Guangdong,China: a prospective observational cohort study

BackgroundChronic obstructive pulmonary disease (COPD) is a heterogeneous disease and its clinically relevant subtypes are not well understood. Which clinical characteristics are more likely to be present among individuals who develop COPD remains to be studied in depth. Therefore, we designed a prospective observational cohort study, entitled the Early Chronic Obstructive Pulmonary Disease (ECOPD) study, to fill this evidence gap. The ECOPD study has four specific aims: (I) identification of characteristics, parameters, and biomarkers that may predict the development of airflow obstruction and annual decline in lung function with normal spirometry; (II) identification of clinically relevant early COPD subtypes; (III) identification of characteristics, parameters, and biomarkers that may predict disease progression in these early COPD subtypes; (IV) development and validation of machine learning models to predict development of airflow obstruction and disease progression.MethodsWe will recruit approximately 2,000 participants aged 40–80 years, including approximately 1,000 with COPD [post-bronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) <0.7] and approximately 1,000 without COPD, using a population-based survey for COPD. We will assess all participants using standard respiratory epidemiological questionnaires, pulmonary function tests [pre-bronchodilator and post-bronchodilator spirometry, and impulse oscillometry (IOS)], health outcomes [modified British Medical Research Council (mMRC) dyspnea scale, COPD assessment test (CAT), COPD clinical questionnaire (CCQ)], inspiratory and expiratory chest computed tomography (CT), and biomarker measurements (blood and urine), as well as satellite remote sensing pollutant exposure measures. Subgroup will additionally complete induced sputum, exercise capacity tests [6-minute walk test (6MWT) and cardiopulmonary exercise testing (CPET)] and home monitoring/personal sampling as pollutant exposure measures. Study procedures will be performed at baseline and every 1 year thereafter.DiscussionThe ECOPD study will provide insight into many aspects of early COPD and improve our understanding of COPD development, which may facilitate therapeutic interventions with the potential to modify the course of disease.Trial RegistrationChinese Clinical Trial Registry, ChiCTR1900024643. Registered on 19 July, 2019.     

慢性阻塞性肺疾病与心血管疾病相关性研究进展

众所周知,慢性阻塞性肺疾病是一种常伴随有显著肺外表现的慢性炎症性疾病,心血管疾病风险增加即此类肺外表现之一。慢性阻塞性肺疾病与心血管疾病之间相关机制复杂,吸烟、衰老、缺氧、全身性炎症、氧化应激及用药等多种因素均可能参与其中。现就其潜在关联机制的研究现状予以综述。     

GOLD2011分类方法对COPD患者评估的初步探索

目的应用2011版慢性阻塞性肺疾病全球创议（GOLD）中的COPD分组评估方法与2007版GOLD分级方法进行对比研究,初步了解两种方法对我国COPD患者病情评估可能存在的差异及其预后价值。方法调查2011年1月1日至2012年1月1日期间就诊于北京同仁医院呼吸科,经肺功能检查明确诊断为COPD的245例稳定期患者。收集基本资料,进行肺功能、COPD评估测试（CAT）问卷,并随访1年,了解患者因急性加重就诊次数及死亡情况。所有患者均按照2011版GOLD及2007版GOLD评估方法分别进行分组,比较其GAT评分、急性加重风险及病死率差异。结果①应用2007版分级方法患者主要集中分布于GOLD2级（n=112,45．71％）及GOLD3级（n=103,42．04％）;而应用2011版分组方法患者集中分布于D组（n=152,62．04％）。②2011版各组间病死率及未来一年因AECOPD就诊次数差异均有统计学意义（P〈0．05）。③D组的三个亚组在年龄、CAT评分、未来一年因AECOPD就诊次数及病死率方面差异均具有统计学意义（P〈0．05）。结论在我们的观察病例中,2011版GOLD分类对疾病加重风险及潜在死亡风险的评估优于2007版GOLD。但这一新的评估和分类方法对于临床和预后的普遍意义,仍需大样本前瞻性研究来进一步证实。     

Streptococcus Pneumoniae Urinary Antigen Test and Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Abstract

Background : Streptococcus pneumoniae is one of the most common bacteria identified in sputum obtained from subjects with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Purpose : To examine the urinary pneumococcal antigen test in subjects admitted with AECOPD and subjects with COPD, and to evaluate its relationship with AECOPD. Methods: Urine samples from 82 subjects with AECOPD involved in 122 consecutive hospitalizations were tested. Additionally, 196 consecutive subjects with stable COPD were tested a total of 607 times at intervals greater than 6 months. Results: Pneumococcal antigen was positive in 14 (17.1%) out of all 82 subjects first hospitalized with AECOPD. It was positive in 7 (20.6%) out of the 34 subjects with pneumonic exacerbations of COPD, and in 7 (14.6%) out of the 48 subjects with non-pneumonic exacerbations of COPD. Two subjects with non-pneumonic S. pneumoniae-related AECOPD were identified, and they both tested positive. A total of 607 urinary antigen tests were performed on stable COPD subjects, and 16 (2.6%) specimens were positive. Colonization by S. pneumoniae was found in the sputum of only 25% of the COPD subjects with positive urinary pneumococcal antigen test results. Conclusion: The results of the pneumococcal urinary antigen test were similar for AECOPD subjects with and without pneumonia. This test may be a useful method for preventing the under-diagnosis of S. pneumoniae-related exacerbations of COPD. The detection of pneumococcal antigen in the urine is not related to the persistent colonization of the respiratory mucosa by S. pneumoniae.