Elsevier

Mayo Clinic Proceedings

Volume 93, Issue 10, October 2018, Pages 1488-1502
Mayo Clinic Proceedings

Review
COPD Guidelines: A Review of the 2018 GOLD Report

https://doi.org/10.1016/j.mayocp.2018.05.026Get rights and content

Abstract

Global Strategy for the Diagnosis, Management, and Prevention of COPD 2018 is a consensus report published periodically since 2001 by an international panel of health professionals from respiratory medicine, socioeconomics, public health, and education comprising the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The GOLD documents endeavor to incorporate latest evidence and expert consensus and are intended for use as “strategy documents” for implementation of effective care for chronic obstructive lung disease (COPD) on a global level. The GOLD 2018 report defines COPD as a “common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases,” with the criteria of “persistent respiratory symptoms” being a new and controversial inclusion since 2017. With the availability of newer pharmacotherapy options, treatment recommendations are made on the basis of a review of the latest literature and directed by symptom burden and health care utilization. Apart from the change in definition, a major shift in the recommendations is the exclusion of severity of airflow limitation as one of the major factors in guiding therapy. We review the salient features of the GOLD 2018 document and provide commentary on features that merit further discussion based on our clinical experience and practice as well as literature review current as of February 2018.

Section snippets

GOLD Background

In 1998, the National Heart, Lung, and Blood Institute established the Global Initiative for Chronic Obstructive Lung Disease (GOLD).1 Its purpose was to focus attention on the management and prevention of chronic obstructive pulmonary disease (COPD), the fourth (now third) leading cause of mortality and morbidity in the United States.2 The original expert panel included a diverse group of health professionals from respiratory medicine, socioeconomics, public health, and education. They

Chapter 1: Definition and Overview

The GOLD document states that “COPD is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases.”5, 6 In the 2017 revision, GOLD had revised the definition of COPD to include “persistent respiratory symptoms” as an essential feature; however, the reasoning behind this has not been provided and the definition

Chapter 2: Diagnosis and Initial Assessment

According to GOLD, the diagnosis of COPD requires 3 features: (1) a postbronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio of less than 0.70, which “confirms the presence of persistent airflow limitation,” (2) “appropriate symptoms” including dyspnea, chronic cough, sputum production, or wheezing, and (3) “significant exposures to noxious stimuli” such as a history of smoking cigarettes, or other environmental exposures.5, 6 Most research studies of

Chapters 3 and 4: Evidence and Recommendations for Management of Stable COPD

The GOLD 2018 document addresses recommendations for management of the nonexacerbating patient with COPD in chapter 4 within the domains of identification and reduction of risk factors, pharmacologic and nonpharmacologic treatment modalities, and monitoring and follow-up after having elucidated the evidence behind these recommendations in chapter 3. The 2 chapters address the same topics from different but overlapping angles; we therefore combined their discussion into 1 section.

After a brief

Chapter 5: Management of Exacerbations

The GOLD group defines an acute exacerbation of COPD (AECOPD) as “an acute worsening of respiratory symptoms that results in additional therapy,” and an event that has the largest impact on patients’ quality of life and cost of care. Aside from the obvious burdens of financial impact, health care utilization, and disruptiveness of COPD exacerbations, they carry the risks of death, iatrogenic complications, setbacks to quality of life, and a somewhat faster decline of lung function.45, 46

Given

Chapter 6: COPD and Comorbidities

Chapter 6 highlights the impact of comorbidities on patients with COPD. In fact, most patients with COPD die from smoking-related comorbidities. Lung cancer and cardiovascular mortality account for most deaths of patients with COPD.74, 75 Symptoms of COPD, such as dyspnea, may be the manifestation of comorbidities such as congestive heart failure, lung cancer, pulmonary embolism, and even depression and deconditioning.

The GOLD document highlights 2 principles in approaching patients with COPD

Discussion and Critique

The GOLD Guidelines have generated controversy since the very first. The current edition is no exception. The GOLD panel includes a distinguished group of COPD experts, whose opinions we hold in high regard. We point out the following, which are in order of importance in our estimation.

Conclusion

The GOLD 2018 document presents a global resource as the authoritative evidence-based review and guide for the diagnosis, management, and prevention of COPD by a distinguished panel of experts. The importance of COPD is magnified by the increasing global burden of this disease. The new guidelines recognize an important evolution in the primary selection and use of long-acting bronchodilators vs inhaled corticosteroids for the prevention of exacerbations. Although a crucial change is

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    Potential Competing Interests: Dr Scanlon reports honoraria paid to his institution for research consultation to Boehringer Ingelheim and GlaxoSmithKline, royalties paid by Wolters Kluwer Lippincott for the book Interpretation of Pulmonary Function Tests, as well as grant support from Astra Zeneca, Boehringer Ingelheim, Forest Laboratories, GlaxoSmithKline, Novartis Pharmaceuticals, and Pearl Therapeutics paid to his institution in support of clinical trials. The rest of the authors report no competing interests.

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