What Are the Four GOLD System Stages of COPD?


Chronic obstructive pulmonary disease (COPD) is a long-term (chronic) condition. COPD is described according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) system using four stages. The goals of the GOLD system are to increase awareness of COPD and lower the morbidity (illness from a disease) and mortality rate (death from a disease).

COPD is a major cause of illness and death throughout the U.S. as well as across the globe. In fact, according to a report by the World Health Organization (WHO), COPD is the fourth leading cause of death in the world. The GOLD system was started in 1997 by several major organizations that focus on health, including WHO.

the 4 stages of COPD
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The Four GOLD Stages of COPD

People with COPD develop lung damage from emphysema and long-term (chronic) bronchitis. The disease keeps the lungs from functioning normally. COPD is not just a single disease entity, but rather, a continuum of symptoms that begin with mild symptoms, progressing to a very severe stage.

The GOLD system aims to classify the severity of the disease based on symptoms and lung function, as well as the prevalence of flare-ups.

The stages of COPD include:

  • Stage I: Early
  • Stage II: Moderate
  • Stage III: Severe
  • Stage IV: Very severe

Each stage can involve various symptoms and requires different diagnostic parameters. Usually, a different treatment plan will be initiated as a person's COPD progresses from one stage to the next.

Some symptoms and treatment modalities overlap from one stage to another, but the symptoms continue to worsen with the progression of the disease, from stage I to stage IV. Identifying the four stages of COPD enables healthcare providers to track a person’s progress, identify the severity of the disease (at each stage) as well as optimize treatment for the condition.

Stage I: Early Stage COPD

During the early stages of COPD an abnormal inflammatory response is present in the lungs, there is an obstruction of normal airflow through the lung's airways, and there's an abnormal pulmonary (lung) and systemic (throughout the entire body) immune response to long-term noxious particle exposure (usually from cigarette smoke).

Symptoms of Stage I COPD

Stage I is the stage in which COPD begins. It may be a very gradual process, taking years to develop. In this earliest stage, you may not have any symptoms at all.

The early stage of COPD may begin with an annoying cough that won’t subside. The cough can be productive (meaning it produces mucus) or it could be a dry cough.

Other symptoms that may be present during this initial stage of COPD include fatigue and/or shortness of breath (particularly when exerting one’s self). During this stage, many people assume that they have allergies, or are simply prone to catching colds.

But, by the time a person begins experiencing symptoms, lung damage has typically already begun. Because of this, it’s important to know the risks of COPD (such as smoking and exposure to environmental pollutants) and to be aware of the common signs and symptoms of the disease.

Early diagnosis and intervention can provide an opportunity for the most effective COPD treatment, leading to better outcomes.

If you have breathing problems, it’s important to consult with your healthcare provider, particularly If you have been a smoker or you have worked (or lived) in an environment that has poor air quality.

Diagnosis of Stage I COPD

There are two primary tests that your healthcare provider will most likely perform to diagnose COPD. These include a physical examination and a spirometry test.

A spirometry test involves deep breathing and blowing out into a tube connected to a meter that measures the pressure of airflow, called a spirometer. This test measures how well the lungs are functioning.

In stage I, the spirometry reading is equal to or below 80% forced expiratory volume (FEV1) in one second (of normal breathing/lung capacity) with moderate airflow limitation.

Other tests for COPD may include:

  • Chest X-ray
  • Computerized tomography (CT) scan
  • Alpha-1-antitrypsin (AAt) test to test for a protein made in the liver that protects that lungs from damage and disease
  • Blood work
  • Other lung tests

Management of Stage I COPD

The most important (and effective) measure to take during the initial stage of COPD is to stop smoking if you are a smoker. If you live or work with a smoker, it’s important to avoid secondhand smoke as well. Other preventative measures for COPD may include:

  • Increase activity. If you are not very active, get off the couch and start getting involved in some activities (including sports, biking, walking, etc.).
  • Start a regular exercise routine (with the approval of your healthcare provider). Exercise will improve the body’s ability to utilize oxygen.
  • Improve nutrition. Eat a healthy diet, comprised of a variety of bright-colored fruits and vegetables (such as the Mediterranean diet). A healthy diet will help strengthen the body’s immune system, staving off colds and infections.
  • Evaluate your environment. If you live or work in an area that has a high level of pollutants (such as living next to or working in an industrial area), consider using indoor HEPPA air filters, move to a different location that has cleaner air and/or consider changing jobs.
  • Avoid triggers. These include dust, mold, pollen, smoke, perfume, and other airborn pollutants.
  • Avoid the use of strong chemicals for cleaning or in the workplace.

Smoking Cessation During Stage I COPD

When considering lifestyle interventions for COPD, it’s very important to look at the impact of smoking cessation. In a 2019 study, it was discovered that even smokers who did not meet the criteria for COPD (measured by spirometric measurements), reported cough and mucus production.

This group was categorized as GOLD stage 0 (at risk for COPD). In fact, 42% of those in the study who were smokers, considered at stage 0, showed radiological (X-rays) evidence of emphysema and airway disease. The study authors wrote, “Smoking cessation is the most effective intervention for preventing COPD and slowing disease progression.”

Treatment for Stage I COPD

Medical treatment for the early stage of COPD may include an inhaler, such as a short-acting bronchodilator to help open the airways and ease breathing problems. Regular flu shots to help strengthen the immune system and protect your body against respiratory infections that may exacerbate symptoms of COPD.

Stage II: Moderate Stage COPD 

During the second stage of COPD, the condition begins to impact life on a day to day basis, adversely affecting a person’s activity level and overall health.

Symptoms of Stage II COPD

Symptoms that are commonly present during stage II COPD include:

  • Chronic (frequent, long-term) productive cough, that is usually worse in the morning, becoming more severe (compared to stage I)
  • Fatigue, which may be mild or severe, depending on many different factors (such as activity level, presence of exacerbation, and more)
  • Shortness of breath severe enough to make daily activities, even minor activities, difficult
  • Wheezing (caused by air passing through obstructed airways)
  • Difficulty sleeping
  • Forgetfulness, confusion, or slurred speech
  • Exacerbation (flare-ups) which occur when symptoms get much worse for a few days, and may present a need for a change in medication

Stage II COPD is usually when people seek medical advice.

Diagnosis of Stage II COPD

Your healthcare provider will diagnose stage II COPD if your spirometry test measures between 50% to 79% forced expiratory volume (FEV1) in one second. The FEV1 reading is the measurement of the lung’s ability to expire air.

Management of Stage II COPD

Pulmonary rehabilitation involves supervision and teaching conducted by your rehabilitation team (this may include physicians, nurses, respiratory therapists, physical therapists, exercise experts. and dietitians). Together, these healthcare professionals develop a personal intervention program to meet the specific needs of each person with COPD.

The pulmonary rehab program includes:

  • Peer groups/support (with others who have COPD)
  • Exercise training
  • Health education
  • Smoking cessation program
  • Symptoms management
  • Breathing techniques
  • Education on healthy diet

Treatment of Stage II COPD

Medical/pharmacological treatment for stage II COPD may include long-acting inhalers/bronchodilators.

Stage III: Severe COPD

A person with stage III COPD will begin to experience symptoms that are more severe; these include:

  • An intensified level of cough and shortness of breath
  • Frequent flare-ups
  • Respiratory infections (recurrent colds, bronchitis, or pneumonia)
  • Headaches (particularly in the morning)
  • Rapid breathing
  • Lips or nail beds that turn blue
  • Swelling in the legs, ankles or feet
  • Difficulty with deep breathing
  • Decrease in level of mental alertness/mental confusion
  • Trouble sleeping

Diagnosis of Stage III COPD

Diagnosis of stage III COPD is made when the lungs are around 30% to 50% capacity of their normal functioning ability. Your healthcare provider will diagnose stage II COPD if your spirometry test measures between 30% to 49% forced expiratory volume (FEV1) in one second.

Management of Stage III COPD

When a person has stage III COPD, it’s important to engage in a pulmonary rehabilitation program (if one has not already done so). Experts say that regular exercise and health management training, as well as breathing exercises and other types of rehabilitation, taught by an expert, (such as a respiratory therapist) is one of the most effective treatment modalities for people with severe COPD.

Although symptoms are severe at this stage, it’s just as important (and perhaps even more so) to stay active as with earlier stages of the disease. As before, staying on a healthy diet, exercising (with your healthcare provider's approval), and avoiding smoking and environmental pollutants is important.

Treatment for Stage III COPD

Frequent checkups may be needed to test your pulmonary function and evaluate your response to medications Your healthcare provider may prescribe a steroid inhaler (to help decrease inflammation in the lungs)

Supplemental oxygen therapy may be ordered (note, oxygen therapy is not necessarily ordered during a specific stage of COPD, but, rather, it will be prescribed according to your symptoms. Most often, oxygen is prescribed for those with resting hypoxia (low oxygen levels when resting).

It can also be prescribed during periods of exacerbation, but some research evidence shows that oxygen therapy can be both harmful and helpful for COPD flare ups. Be sure to talk to your healthcare provider if you have questions about oxygen therapy.

Stage IV: Very Severe COPD

Over time, the irreversible damage to the lungs, caused by COPD, spreads to areas where oxygen is exchanged; this results in emphysema. In the later stages of COPD, the lungs have stopped being able to provide the body with an adequate supply of oxygen.

This, in turn, impacts other organs, such as the heart and the pulmonary artery. The heart must work harder to pump the blood, which can result in heart disease. Water retention can occur as the heart becomes weaker and fluid may pool, causing swelling in the lower extremities (the feet, legs and ankles).

Symptoms of Stage IV COPD

During the final stage of COPD, the condition starts to seriously impact every activity a person engages in. Also, in this stage, shortness of breath is often present, even when a person is resting. When the blood oxygen level is low, while a person is inactive, this is referred to as resting hypoxia.

The symptoms of stage IV may involve all the symptoms from the other stages of COPD, but they worsen. For example:

  • Weight loss (common)
  • Morning headaches
  • Breathing takes effort
  • Extreme difficulty with daily tasks such as dressing or showering
  • Delirium
  • Wheezing
  • Increased heart rate (even when resting)
  • High blood pressure in the pulmonary artery (the artery that transports blood from the heart to the lungs).
  • Severe infections
  • Symptoms that may require emergency hospitalization

Exacerbation episodes are more frequent, can be more severe, and can be fatal. Shortness of breath is so severe that it may impact the body’s circulation, affecting the heart due to lack of oxygen and proper airflow (this can result in cardiovascular complications).

Morning Headaches

Frequent morning headaches in people with COPD are commonly caused by several factors, including:

  • Low levels of carbon dioxide in the blood (caused by lung damage which renders the lungs unable to efficiently remove carbon dioxide)
  • High levels of oxygen in the blood (hypoxia, caused by lung damage which interferes with the amount of oxygen that the lungs are able to absorb in the tiny structures called alveoli)

Additional symptoms may include;

  • An increased risk of many other conditions such as heart conditions and other circulatory problems, diabetes, and arthritis.
  • Chronic respiratory failure caused by low levels of oxygen and a build-up of carbon dioxide (CO2)
  • Crackles, believed to be caused by the re-opening of collapsed airways caused by long-term inflammation and lung secretions.  
  • Barrel chest due to constant over-inflation of the lungs
  • Chest pain
  • Drowsiness
  • Depression

Diagnosis of Stage IV COPD

In stage IV COPD, the lungs are only functioning at 30% (or less) of normal capacity. Your healthcare provider will diagnose stage IV COPD if your spirometry test measures less than 30% of forced expiratory volume (FEV1) in one second.

Management of Stage IV COPD

The management of stage IV COPD normally remains the same as during stage III. It’s important to continue to stay as active for as possible, quit smoking or if you have already quit, stay off of cigarettes, e-cigarettes, or other smoking apparatus. Don’t forget the old adage, “You’re always a cigarette away from a pack per day."

Stay on your diet and continue to participate in your pulmonary rehabilitation groups/program. You may need to make adjustments.

If your activity level is severely impacted, consider participating in peer support groups via an online forum or by phone.  Don’t forget to stay on top of regular vaccinations and see your healthcare provider regularly.

Treatment Of Stage IV COPD

Treatment for stage IV COPD may include:

  • A short-acting bronchodilator as needed when breathing is restricted (to help open the airways and ease breathing problems)
  • A long-acting inhaler/bronchodilator
  • Supplemental oxygen therapy

Surgical treatment may include:

  • Lung volume reduction surgery (a portion of the diseased lung tissue is removed)
  • A lung transplant

A Word From Verywell

You may hear stage IV COPD referred to as “end stage chronic pulmonary obstructive disease.” But it’s important to note that many people with COPD live for years, particularly when following the advice of their healthcare provider and maintaining their treatment plan regarding lifestyle changes.

Another key factor is keeping a positive attitude, which can go very far in helping a person cope with any chronic disease. With good medical treatment—even if COPD is in the severe stage—it doesn’t necessarily have to be the driving force in your longevity.

Stick with your healthcare team’s plan, respond promptly to changes in symptoms (such as when flare-ups occur) and engage in some positive activities that you enjoy.

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Article Sources
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