January 2017 saw the publication of new global COPD Guidelines (referred to as GOLD 2017i). These guidelines, which include several major changes on the recommendations for the prevention, diagnosis, and management of COPD in primary care, are based on new evidence published in the last two years.
The changes relate to the ABCD grouping tool, escalation and de-escalation strategies for pharmacological intervention, non-pharmacologic therapies and medical comorbidities.
The 1234 classification of spirometry has been removed from the ABCD grouping tool, which now derives exclusively from patient symptoms and their history of exacerbations. This does not mean that spirometry is not required; indeed GOLD 2017 indicates that spirometry is of the utmost importance in diagnosing COPD however, the assessment of COPD has been refined to separate the diagnosis attained via spirometry from the symptoms and exacerbation risk.
The revised ABCD scheme based on symptoms and exacerbation history alone allows clinicians to immediately initiate a treatment plan in cases of urgent presentation of a known COPD patient.
The ABCD GroupingThe Increasing Dyspnoea scores are mMRC Questionnaire <2 (<10 CAT) for Group A & C. For Groups B & D the questionnaire scores ≥ 2 (≥ 10 CAT). The Increasing Exacerbation scores are 0-1 (not leading to hospital admission) for Groups A & B. For Groups C & D ≥ 2 exacerbations or any hospital admission.
|Grade||Description of Breathlessness|
|Grade 0||I only get breathless with strenuous exercise|
|Grade 1||I get short of breath when hurrying on level ground or walking up a slight hill|
|Grade 2||On level ground, I walk slower than people of the same age because of breathlessness, or I have to stop for breath when walking at my own pace on the level|
|Grade 3||I stop for breath after walking about 100 yards or after a few minutes on level ground|
|Grade 4||I am too breathless to leave the house or I am breathless when dressing|
GOLD COPD Classification (post-bronchodilator FEV1 ratio is <0.7)
|GOLD||FEV1 % of predicted||Airways Obstruction|
|GOLD 1||≥ 80||Mild|
|GOLD 4||<30||Very Severe|
Another significant change contained in Gold 2017 relates to the recommended pharmacological treatments for each of the Groups A to D and their escalation strategies.
ICSii are no longer recommended as first-line treatment for Groups C & D (high exacerbation groups). Short acting bronchodilators (either beta2-agonist or anticholinergic) are no longer recommended in Groups B, C & D, only (possibly) in Group A. There is an emphasis on LAMA or LABA for all Groups escalating to LAMA & LABA in Groups B, C & D. Stopping ICS may be indicated in Group D where exacerbations continue due to the elevated risk of adverse effects such as pneumonia from ICS therapy.
GOLD 2017 also addresses escalation/ de-escalation strategies for pharmacological/ non-pharmacologic therapies and to medical comorbidities; this article does not address these matters. Figure 3 in the 2017 GOLD Guidelines is a very clear and simple diagram of the treatment pathways and escalation strategies; note in particular the green boxes which show the preferred treatment pathways within each Group when exacerbations continue or dyspnoea symptoms persist.
GOLD 2017 Guidelines continue to use a (post-bronchodilator) fixed ratio of FEV1/FVC < 0.70 as the spirometry criterion for airflow limitation. Spirometry result interpretations are now more usually based on the lower limit of normal (LLN) values and the Guidelines recognise that a fixed ratio may result in over diagnosis of COPD in the older people and under diagnosis in people < 45 years old, particularly when their COPD is mild. The rationale is that this keeps it simple and is independent of reference (predicted) values.
There is no value in pre/post bronchodilator (or corticosteroid) spirometry assessment of the degree of reversibility of airflow in COPD since this does not aid the diagnosis of COPD or predict COPD treatment response.
Classification of airflow obstructionSpirometry should be performed after administration of an adequate dose of at least one short-acting inhaled bronchodilator in order to minimize variability. Allow the bronchodilator sufficient time to have a full effect, normally 20 minutes.
The role of spirometry in COPDSpirometry is essential in the diagnosis of COPD The FEV1 ratio is used to ascertain the severity of airflow obstruction Spirometry is used in the follow-up assessment Spirometry can guide therapeutic decisions on:
- Choice of medicines in some circumstances (particularly where there is a discrepancy between spirometry and symptoms)
- Alternative diagnoses
- Non-pharmacological treatments
- Responses to rapid decline
Key points to consider
- COPD should be assessed in any patient who presents with:
- Long term dyspnoea
- Chronic cough
- Prolonged sputum production
- A history of exposure to risk factors such as smoking.
- Spirometry is indispensable in making a diagnosis of COPD.
- If the FEV1 Ratio is less than 0.70 it confirms the presence of persistent airflow limitation.
- Determine the level of airflow limitation with spirometry.
- Assess the patient’s perceived severity of dyspnoea
- Weigh the consequential impact on the patient’s quality of life
- Gauge the risk of future events, e.g. exacerbations, hospital admissions
- Use the above factors to guide therapy.
iGOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD http://goldcopd.org/
- iiSABA = short-acting beta2-agonist
- LABA = long-acting beta2-agonist
- LAMA = long acting muscarinic antagonist
- ICS = Inhaled corticosteroid