New COPD GOLD Classification

Objectives Defining COPD To be familiar with the new GOLD classification system

COPD Defined by GOLD COPD as a disease state is characterized by airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. GOLD=Global Initiative for Chronic Obstructive Lung Disease What is airflow limitation? Post bronchodilator FEV1/FVC ratio less than 0.70

OLD Subtypes Chronic bronchitis: Emphysema: chronic productive cough for 3 months in 2 consecutive years. Emphysema: Abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of airspace walls without obvious fibrosis. Chronic obstructive asthma: Asthma with airflow obstruction that does not remit completely REFERENCE SLIDE to show that current definition of COPD no longer separates these subtypes due to the spectrum of manifestations and related processes If asked why exclusion of fibrosis for emphysema? Intended to distinguish emphysema from interstitial pneumonias. However, many studies indicate that fibrosis can be a component of emphysema and less commonly, emphysema can exist in individuals who do not have airflow obstruction  If asked for definition of Asthma: (National Asthma Education and Prevention Program Expert Panel) -a chronic inflammatory disorder of the airways. The chronic inflammation is associated with airway responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variably, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

revised GOLD classification Looks at 3 things: Symptoms FEV1 History of exacerbations Why the new system? A good question for the listeners is, what if two patients are in the same class but different exercise tolerance or functional capacity? They should not be treated the same, therefore, the revised GOLD classification uses symptoms, FEV1, history of exacerbations to assess the exacerbation risk and guide therapy

Grading symptoms This is how symptoms are graded in the new system. Can either use this-MMRC or CAT scale

Grading severity of airflow In patients with FEV1/FVC <0.70 GOLD 1 Mild FEV1>80% GOLD 2 Moderate 50%<FEV1<80% GOLD 3 Severe 30%<FEV1<50% GOLD 4 Very severe FEV1<30% Point out that FEV1/FVC ratio used to be the only factor in the old classification system. In a sense, we are using the same 1-4 ratios of FEV1 as the old system here, but it is now one of three factors in the new classification system

history Putting it all together for the new classification system. Going from top to bottom, symptoms, airflow limitation, and exacerbations-which is based on low risk=less than or equal to 1 per year or high risk=greater than or equal to 2 per year. Then going down to bottom half of table 4, notice that A and B are low risk -> C and D highest risk. Pick the highest risk column that spirometry or exacerbation history fits into.

CASE 74 YO M with COPD p/w SOB x 2 days. At baseline he does not have any physical limitations. His last spirometry three years ago showed mild COPD. He was never given any inhalers besides a rescue inhaler that he seldom uses. He has never been intubated, but gets about 3 exacerbations per year. 2 days ago he required it around the clock after having URI symptoms. He has increased greenish sputum over the past couple of days. He called 911 after waking up SOB. He was given duonebs and placed on CPAP. What classification is he? Grade 0 symptoms, Grade 1 spirometry, >2 exacerbations. So class C

summary COPD is characterized by airflow limitation, progressive, and has an enhanced chronic inflammatory response. Revised GOLD classification uses FEV1, symptoms, history of exacerbations It’s still important to know the OLD FEV1 classification system because it’s used in the NEW GOLD classification. For diagnosis and exacerbation treatment of COPD, see the newly revised COPD mini lecture!

References Global Strategy for the Diagnosis, Management, and Prevention of COPD Updated 2013 Uptodate