Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guide

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) pocket guide to chronic obstructive pulmonary disease (COPD) diagnosis and prevention is updated yearly, based on the Global Strategy for the Diagnosis, Management, and Prevention of COPD report.

The guide provides a review of the causes and management of COPD and it is meant to be a resource for doctors who treat the condition. The document is freely accessible online without membership or password.

Definition of COPD

COPD is a common, preventable, usually progressive, respiratory illness with symptoms that include dyspnea (shortness of breath), a persistent cough, and sputum production. The condition can cause exacerbations, which are sudden episodes of worsening symptoms. People who have COPD often experience recurrent lung infections.

Smoking and exposure to airborne toxins are the major risk factors for developing COPD. It is common to also have other serious medical problems along with COPD. The disease is characterized by a limitation of airflow in the airways of the lungs and destruction of the lung tissue.

Diagnosis

The GOLD pocket guide provides direction regarding the diagnosis and classification of COPD. The GOLD guide recommends ruling out other respiratory conditions that can also cause dyspnea, cough, and sputum production when the diagnosis of COPD is being considered.

These conditions include:

• Asthma
• Lung cancer
• Left-sided heart failure
• Bronchiectasis
• Tuberculosis
• Interstitial lung disease
• Cystic fibrosis
• Idiopathic (without a known cause) cough
• Obliterative bronchiolitis
• Diffuse panbronchiolitis

Spirometry

Spirometry, an interactive process that requires breathing into a mouthpiece, is a required component of COPD diagnosis. The amount of air you can inspire and expire using a spirometer is measured and compared to standard values (which are based on factors such as age, gender, and height).

One of the measures obtained with spirometry is the amount of air you can expire in one second—forced expiratory reserve volume (FEV1). Your medical team will also measure the amount of air you can exhale after taking the deepest breath possible—forced vital capacity (FVC).

When your FEV1/FVC is less than 70%, your airflow limitation severity in COPD can be classified based on post bronchodilator FEV1. This means that your FEV1 is measured after you are treated with a bronchodilator.

Classification according to the GOLD recommendations are:

• GOLD 1 mild: FEV1 greater than 80% predicted
• GOLD 2 moderate: FEV1 is between 80% to 50% of predicted
• GOLD 3 severe: FEV1 is between 50% to 30% of predicted
• GOLD 4 very severe: FEV1 is less than 30% of predicted

Symptomatic Grading

According to the GOLD guide, spirometry assessment is not enough to determine the impact of COPD on a person’s health or to guide therapy.

Other considerations include an evaluation of the following:

• Type, frequency, and severity of symptoms
• History of exacerbations
• Presence of other illnesses

The Modified Medical British Research Council (mMRC) dyspnea scale is a formal COPD assessment that takes symptoms into account.

Grading is as follows:

• Grade 0: You are only breathless with strenuous exercise
• Grade 1: You are short of breath when hurrying on level ground or walking up a hill
• Grade 2: You walk slower than most people of the same age because of breathlessness or stop for breath while walking
• Grade 3: You stop for breath after walking approximately 100 meters or for a few minutes on level ground
• Grade 4: You are too breathless to leave the house or breathless when dressing and undressing

And the COPD Assessment Test (CAT) includes eight factors that you will be asked to rate on a scale from zero to five, with five being the most severe designation. The numbers are added up to help your medical team grade your COPD.

Items to rate include:

• Never coughing/coughing all the time
• No phlegm/chest full of phlegm
• No chest tightness/chest very tight
• No breathlessness when walking up stairs or up a hill/very breathless walking up a hill or one flight of stairs
• Not limited doing activities at home/very limited in activities at home
• Confident leaving home/not confident leaving home because of lung disease
• Sleeping soundly/not sleeping soundly
• Lots of energy/no energy at all

COPD Grading

Utilizing these objective measures can help your medical team come up with the best treatment plan for your individual needs. The refined ABCD assessment tool for COPD includes consideration of post-bronchodilator spirometry, mMRC scale, CAT assessment, and the number of exacerbations. Several factors are considered as COPD is graded A, B, C, or D (A is mild and D is severe).

High grade COPD is consistent with:

• Having an MRC greater or equal to two
• A total CAT score higher than 10
• More than two exacerbations or more than one requiring hospitalization

Treatment

The management of COPD includes a variety of strategies. Smoking cessation, medications, and pulmonary rehabilitation are the leading strategies discussed in the GOLD guide.

Prevention

The GOLD guide recommends smoking cessation and does not promote the use of e-cigarettes due to safety concerns. Smoking leads to COPD and continuing to smoke with COPD worsens the disease, increasing the risk of exacerbations.

Lung infections exacerbate COPD. It can be difficult to recover from a lung infection if you have the disease. Vaccination can prevent certain contagious infections.

According to the GOLD guide, vaccination recommendations for COPD include a 20-valent pneumococcal conjugate vaccine (PCV20) or 15-valent pneumococcal conjugate vaccine (PCV15) followed by a 23-valent pneumococcal polysaccharide vaccine (PPSV23), influenza vaccination, Tdap (for pertussis), zoster, and COVID-19 vaccination.

Medication

There are several medications used in the treatment of COPD. These medications include daily treatments that prevent symptoms and as-needed treatments that can alleviate worsening symptoms.

Beta-2 agonists: The guide describes the recommended use of bronchodilators, which are medications that widen the airways to make breathing easier. Selective beta-2 agonists are medications that relax the airways.

Short acting beta-2 agonists (SABAs) and long acting beta-2 agonists (LABAs) are both recommended. According to the guide, LABAs should be used daily to prevent respiratory problems. And SABAs can improve symptoms, but should not be used regularly.

Antimuscarinics: These are medications that counteract constriction (tightening) of the airways. Long-acting antimuscarinics (LAMAs) and short-acting antimuscarinics work similarly but have different durations of action.

Methylxanthines: The guide mentions these medications, which include theophylline, with a comment that they are controversial and that the evidence regarding their effects is not clear.

Combination therapy: The guidelines note that combination bronchodilator therapies can be more effective in reducing symptoms and improving FEV1 values than therapies which contain only one medication.

For people who have moderate or severe COPD and experience shortness of breath and/or exercise intolerance, the American Thoracic Society's (ATS) 2020 guidelines recommend that a combination of both a long-acting beta-agonist (LABA) and a Long-acting anticholinergic/muscarinic antagonist (LAMA) be used, rather than either of these types of bronchodilators alone.

Anti-inflammatory therapy: The guidelines discuss anti-inflammatory therapy, including steroids, and mentions the risks and benefits. Benefits include possibly reducing exacerbations, and risks include a predisposition to infections.

Phosphodiesterase-4 (PDE-4) inhibitors: These medications reduce inflammation and can be added to a medication regimen that includes LABAs or steroids.

Antibiotics: These medications are used to fight bacterial infections. They have been studied as preventative treatments on COPD, and, according to the guide, taking antibiotics on a regular basis does not reduce exacerbations.

Interventions and Specialist-Driven Procedures

Besides prevention and medication, other interventions for the management of COPD described in the guide include pulmonary rehabilitation, supplemental oxygen, ventilator support, and surgery.

Pulmonary rehabilitation involves exercise and education about the illness. Oxygen supplementation at home can help a person with COPD breathe easier and have more energy. This approach is needed if the blood oxygen saturation is below normal levels, which can occur in late-stage COPD or during a lung infection.

Ventilator support, including non-invasive ventlation, may be needed during an exacerbation or a severe lung infection.

Surgery is not a typical option for COPD, but it may be beneficial for people who have a focused area of lung damage. Specialized less invasive procedures (valves placed by bronchoscopy) and lung transplantation are other considerations in severe patients.

A Word From Verywell

You might feel some uncertainty after being diagnosed with COPD. And if you have other medical issues, you may be seeing several different medical specialists for therapy and to get your medications adjusted. The GOLD pocket guide provides methodical standards regarding the diagnosis and treatment of COPD, which can help your medical team manage your condition in a consistent way.