Practical Pearls from the GOLD Guidelines on COPD

By Juan Garcia, MD, FCCP; and Stephen Jenkinson, MD, FCCP

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Assess and Monitor Disease

The diagnosis of COPD by the GOLD guidelines1 is defined as follows: “COPD is a disease state characterized by airflow limitation that is usually not fully reversible. The airflow limitation is often both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.” The diagnosis of COPD is made on the basis of symptoms, which may include those due to airway irritation (cough and sputum production) and those reflecting altered lung mechanics (breathlessness, wheezing, and sometimes chest pain). Cough and sputum production usually precede the development of airflow limitation by many years, although not all individuals with symptoms of cough and sputum production go on to develop COPD.¹

Pearl: The GOLD guidelines classify the severity of COPD into four stages.

Stage 0, At Risk. Characterized by symptoms of cough and sputum production not solely due to asthma, nasal disease, or gastric reflux. Lung function, as measured by spirometry, is still normal.

Stage I, Mild Risk. Characterized by mild airflow limitation (FEV₁/FVC < 70% but FEV₁ ≥ 80% predicted) and usually, but not always, by the continued presence of cough and sputum production. At this stage, the individual may not even be aware that his or her lung function is abnormal.

Stage II, Moderate COPD. Characterized by worsening airflow limitation (FEV₁/FVC < 70% and FEV₁ < 80% and ≥ 30% of predicted), and usually the progression of symptoms, with shortness of breath typically developing on exertion. Exacerbations may be troublesome and frequently lead to a significant decrease in the patient’s quality of life. Patients typically seek medical attention at this stage.

Stage III, Severe COPD. Characterized by severe airflow limitation (FEV₁/FVC < 70% and FEV₁ < 30% predicted) plus the presence of respiratory failure or clinical signs of right heart failure. At this stage, quality of life is appreciably impaired and exacerbations may occur three to four times per year and may be life-threatening.

Pearl: Use of accessory muscles of respiration, such as the abdominal rectus, on expiration is a sign of advanced disease. Physical findings of hyperinflation include an increased anteropsoterior diameter of the chest, tracheal tug, or pulsus paradoxus > 20 mm Hg.

Pearl: Arterial blood gas measurement is indicated in patients with FEV₁ < 40%, or in patients with signs of respiratory failure or right heart failure

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