Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary

TL;DR: The assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation, and the concept of deescalation of therapy is introduced in the treatment assessment scheme.

Abstract: This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 report focuses primarily on the revised and novel parts of the document. The most significant changes include: (1) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; (2) for each of the groups A to D, escalation strategies for pharmacologic treatments are proposed; (3) the concept of deescalation of therapy is introduced in the treatment assessment scheme; (4) nonpharmacologic therapies are comprehensively presented; and (5) the importance of comorbid conditions in managing chronic obstructive pulmonary disease is reviewed.

Summary

Factors That Influence Disease Development and Progression

• Epidemiologic studies demonstrate that non-smokers may also develop chronic airflow limitation.
• 3 Compared to smokers with COPD, never smokers with chronic airflow limitation have fewer symptoms, milder disease and a lower burden of systemic inflammation.
• 4 Processes occurring during gestation, birth, and exposures during childhood and adolescence affect lung growth.

Diagnosis

• COPD should be considered in any patient with dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease .
• Spirometry is required to make the diagnosis in this clinical context 31 ; a postbronchodilator FEV 1 /FVC < 0.70 confirms the presence of persistent airflow limitation and identifies the presence of COPD in patients with appropriate symptoms and predisposing risks.

Recurrent lower respiratory tract infections History of risk factors:

• Host factors (such as genetic factors, congenital/developmental abnormalities etc.).
• Smoke from home cooking and heating fuels.
• Occupational dusts, vapors, fumes, gases and other chemicals.

Symptoms

• Chronic and progressive dyspnea is the most characteristic symptom of COPD.
• The terms used to describe dyspnea vary individually and culturally.
• Chronic cough is often the first symptom of COPD and frequently discounted by the patient as a consequence of smoking and/or environmental exposures.
• Patients producing large volumes of sputum may have underlying bronchiectasis.
• Wheezing and chest tightness may vary between days, and throughout a single day.

Medical History

• Past medical history, including asthma, allergy, sinusitis, or nasal polyps; respiratory infections in childhood; other chronic respiratory and non-respiratory diseases.
• Pattern of symptom development: age of onset, type of symptom, more frequent or prolonged "winter colds," and social restriction.
• Presence of comorbidities, such as heart disease, osteoporosis, musculoskeletal disorders, and malignancies.
• Social and family support available to the patient.
• Possibilities for reducing risk factors, especially smoking cessation.

Physical examination

• A physical examination is rarely diagnostic in COPD.
• Physical signs of airflow limitation/hyperinflation are usually not identifiable until significantly impaired lung function is present.

Spirometry

• Spirometry is the most reproducible and objective measurement of airflow limitation.
• These findings await additional study in other cohorts.
• The risk of misdiagnosis and over-treatment using the fixed ratio as a diagnostic criterion is limited since spirometry is only one parameter used to establish the clinical diagnosis of COPD.
• GOLD favors using the fixed ratio over LLN since diagnostic simplicity and consistency are crucial for the busy clinician.

Assessment of symptoms

• COPD was previously viewed as a disease largely characterized by breathlessness.
• A simple measure of breathlessness such as the Modified British Medical Research Council (mMRC) Questionnaire 48 was considered adequate for assessment of symptoms 49, 50, 51 However, COPD impacts patients well beyond dyspnea.
• 54 These are too complex to use in clinical practice, but shorter measures e.g., the COPD Assessment Test (CAT TM ) are suitable.

Assessment of exacerbation risk

• Post-hoc analysis of two clinical trials in COPD patients with an exacerbation history showed that higher blood eosinophil counts may predict increased exacerbation rates in patients treated with long acting beta agonists (LABA) (without inhaled corticosteroid, ICS).
• 61, 62 The treatment effect of ICS/LABA versus LABA on exacerbations was greater in patients with higher blood eosinophil counts.
• These findings suggest that blood eosinophil counts are 1) a biomarker of exacerbation risk in patients with a history of exacerbations and 2) can predict the effects of ICS on exacerbation prevention.
• Prospective trials are required to validate the use of blood eosinophil counts to predict ICS effects, to determine a cut-off threshold for blood eosinophils that predicts exacerbation risk, and to clarify blood eosinophil cut-off values that could be used in clinical practice.

Revised combined COPD assessment

• The "ABCD" assessment tool of the 2011 GOLD Report was a major step forward from the simple spirometric grading system of earlier GOLD Reports because it incorporated patient-reported outcomes and highlighted the importance of exacerbation prevention in COPD management.
• Spirometry, in conjunction with patient symptoms and exacerbation history, remains vital for the diagnosis, prognostication and consideration of other important therapeutic approaches, especially non-pharmacological therapies.
• FEV 1 is a very important parameter at the populationlevel in the prediction of important clinical outcomes such as mortality and hospitalizations or prompting consideration for non-pharmacologic therapies such as lung reduction or lung transplantation.
• Furthermore, in some circumstances, such as during hospitalization or urgent presentation to the clinic or emergency room, the ability to assess patients based on Example.
• With the new proposed scheme, the subject with 3 exacerbations in the past year would be labelled GOLD grade 4, group D. Individual decisions on pharmacotherapeutic approaches would use the recommendations based on the ABCD assessment to treat the patient's major problem at this time, i.e., persistent exacerbations.

Alpha-1 antitrypsin deficiency

• The World Health Organization recommends that all patients with a diagnosis of COPD be screened once for alpha-1 antitrypsin deficiency.
• Family members should be screened and together with the patient referred to specialist centres for advice and management.

Additional investigations

• In order to rule out other concomitant disease contributing to respiratory symptoms, or in cases where patients do not respond to the treatment plan as expected, additional testing may be required.
• Thoracic imaging (chest x-ray, chest CT); assessment of lung volumes and/or diffusion capacity, oximetry and arterial blood gas measurement and exercise testing and assessment of physical activity should be considered.

Composite scores.

• The BODE (Body mass index, Obstruction, Dyspnea, and Exercise) method gives a composite score that is a better predictor of subsequent survival than any single component.
• 71 Simpler alternatives that do not include exercise testing need validation to confirm suitability for routine clinical use.

Prevention and Maintenance Therapy Key Points

• Pharmacotherapy and nicotine replacement increase long-term smoking abstinence rates.
• Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.
• Each pharmacologic treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and cost, and the patient's response, preference and ability to use various drug delivery devices.
• Influenza and pneumococcal vaccinations decrease the incidence of lower respiratory tract infections.
• In patients with severe resting chronic hypoxemia, long-term oxygen therapy improves survival.

Smoking Cessation

• Smoking cessation influences the natural history of COPD.
• If effective resources and time are dedicated to smoking cessation, long-term quit success rates of up to 25% can be achieved.
• Nicotine replacement therapy increases long-term smoking abstinence rates [75] [76] [77] and is more effective than placebo.
• E-cigarettes are increasingly used as a form of nicotine replacement therapy, although their efficacy remains controversial. [78] [79] [80] [81] [82].

Smoking cessation programs.

• A five-step program for intervention 86,87 provides a framework to guide healthcare providers to help patients stop smoking.
• 77, 86, 88 Counseling delivered by health professionals significantly increases quit rates over selfinitiated strategies.
• 89 The combination of pharmacotherapy and behavioral support increases smoking cessation rates.

Influenza vaccine and Pneumococcal vaccines

• 92 Vaccines containing either killed or live inactivated viruses are recommended 97 as they are more effective in elderly patients with COPD.
• 98 Pneumococcal vaccinations, PCV13 and PPSV23, are recommended for all patients ≥ 65 years of age .

Overview of medications

• Pharmacologic therapy for COPD reduces symptoms, the frequency and severity of exacerbations, and improves exercise tolerance and health status.
• The choice within each class depends on the availability and cost of medication and favorable clinical response balanced against side effects.
• Each treatment regimen needs to be individualized as the relationship between severity of symptoms, airflow limitation, and severity of exacerbations varies between patients.

Bronchodilators

• Bronchodilators increase FEV 1 , reduce dynamic hyperinflation, at rest and during exercise, 104, 105 and improve exercise performance.
• Bronchodilator medications are usually given on a regular basis to prevent or reduce symptoms.
• Stimulation of beta 2 -adrenergic receptors can produce resting sinus tachycardia and precipitate cardiac rhythm disturbances in susceptible patients.
• Ipratropium, a short acting muscarinic antagonist, provides small benefits over short-acting beta 2 -agonist in terms of lung function, health status and requirement for oral steroids.

Combination bronchodilator therapy

• Combining bronchodilators with different mechanisms and durations of action may increase the degree of bronchodilation with a lower risk of side-effects compared to increasing the dose of a single bronchodilator (Table 3 ).
• These combinations improve lung function compared to placebo 122 and have a greater impact on patient reported outcomes compared to monotherapies. [123] [124] [125] [126].
• LABA/LAMA improves symptoms and health status in COPD patients, 127 is more effective than long-acting bronchodilator monotherapy for preventing exacerbations, 128 and decreases exacerbations to a greater extent than ICS/LABA combination.

Inhaled corticosteroids

• In patients with moderate to very severe COPD and exacerbations, an inhaled corticosteroid (ICS) combined with a LABA is more effective than either component alone in improving lung function, health status and reducing exacerbations.
• Observational studies suggest that ICS treatment could be associated with increased risks of diabetes/poor control of diabetes, 140 cataracts, 141 and mycobacterial infection 142 including tuberculosis.
• Withdrawal studies provide equivocal results regarding the consequences of withdrawal on lung function, symptoms and exacerbations. [145] [146] [147] [148] [149].
• More evidence is needed to compare the benefits of triple therapy (LABA/LAMA/ICS) to LABA/LAMA.

Phosphodiesterase-4 inhibitors

• Roflumilast reduces moderate and severe exacerbations treated with systemic corticosteroids in patients with chronic bronchitis, severe to very severe COPD, and a history of exacerbations.
• The most frequent are diarrhea, nausea, reduced appetite, weight loss, abdominal pain, sleep disturbance, and headache.
• Roflumilast should be avoided in underweight patients and used with caution in patients with depression.

Issues related to inhaled delivery

• Observational studies have identified a significant relationship between poor inhaler use and symptom control in COPD.
• Observational studies suggest a reduction in spirometric progression in alpha-1 antitrypsin deficiency patients treated with augmentation therapy versus non-treated patients.
• Available studies report worsening gas exchange 181 with little improvement in exercise capacity or health status in COPD patients.

Pulmonary Rehabilitation

• Pulmonary rehabilitation is a comprehensive intervention based on thorough patient assessment followed by patient-tailored therapies (e.g., exercise training, education, self-management interventions aimed at behavior changes to improve physical and psychological condition and promote adherence to health-enhancing behaviors in patients with COPD).
• Pulmonary rehabilitation can reduce readmissions and mortality in patients following a recent exacerbation (≤ 4 weeks from prior hospitalization).
• Self-management interventions that use written negotiated action plans for worsening symptoms may lead to less respiratory-related hospitalization and all cause hospitalizations and improved health status.

Other Treatments

• Oxygen Therapy and Ventilatory Support Oxygen therapy.
• The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure increases survival in patients with severe resting hypoxemia.
• Whether to use NPPV chronically at home to treat patients with acute on chronic respiratory failure following hospitalization remains undetermined.
• In patients with both COPD and obstructive sleep apnea continuous positive airway pressure improves survival and avoids hospitalization .

Surgical Interventions

• A RCT confirmed that COPD patients with upperlobe emphysema and low post-rehabilitation exercise capacity experienced improved survival when treated with lung volume reduction surgery (LVRS) compared to medical treatment.
• In patients with high post-pulmonary rehabilitation exercise capacity, no difference in survival was noted after LVRS, although health status and exercise capacity improved.
• In selected patients with relatively preserved underlying lung, bullectomy is associated with decreased dyspnea, improved lung function and exercise tolerance.
• In selected patients lung transplantation has been shown to improve health status and functional capacity but not to prolong survival. [209] [210] [211].
• Bilateral lung transplantation has been reported to have longer survival than single lung transplantation in COPD patients, especially those < 60 years of age.

Bronchoscopic Interventions to Reduce Hyperinflation in Severe Emphysema

• Less invasive bronchoscopic approaches to lung reduction have been developed.
• Two multicenter trials have examined nitinol coils implanted into the lung compared to usual care reported increases in 6 minute walk distance with coil treatment compared to control and smaller improvements in FEV 1 and quality of life measured by St George's Respiratory Questionnaire.

Management of Stable COPD Key Points

• The basis for these recommendations is partially based on evidence generated in RCTs.
• These recommendations are intended to support clinician decision-making.

Identify and Reduce Exposure to Risk Factors

• Cigarette smoking is the most commonly encountered and easily identifiable risk factor for COPD; smoking cessation should be continually encouraged for current smokers.
• Reduction of total personal exposure to occupational dusts, fumes, and gases, and to indoor and outdoor air pollutants, should be addressed.
• The choice within each class depends on the availability of medication and the patient's response and preference (Tables 5-7 ).
• In patients with persistent dyspnea on one bronchodilator treatment should be escalated to two (Evidence A). Inhaled bronchodilators are recommended over oral bronchodilators (Evidence A). Long-term therapy with oral corticosteroids is not recommended (Evidence A). .

Pharmacologic treatment algorithms

• A proposed model for the initiation, and then subsequent escalation and/or deescalation of pharmacologic management according to the individualized assessment of symptoms and exacerbation risk is shown in Figure 3 .
• In past GOLD Reports, recommendations were only given for initial therapy.
• Many COPD patients are already on treatment and return with persistent symptoms after initial therapy, or less commonly with resolution of some symptoms that may subsequently require less therapy.
• Therefore, the authors now suggest escalation and de-escalation strategies.
• These recommendations will be re-evaluated as additional data become available.

Group B

• Initial therapy should be a long acting bronchodilator.
• Long-acting bronchodilators are superior to short-acting bronchodilators taken intermittently.
• For patients with persistent breathlessness on monotherapy 222 the use of two bronchodilators is recommended.
• For patients with severe breathlessness, initial therapy with two bronchodilators may be considered.

Group C

• Initial therapy should be a single long acting bronchodilator.
• In two head-to head comparisons 112, 223 the LAMA tested superior to the LABA regarding exacerbation prevention, therefore the authors recommend initiating a LAMA in this group.
• Patients with persistent exacerbations may benefit from adding a second long acting bronchodilator (LABA/LAMA), or using a combination of a long acting beta 2 -agonist and an inhaled corticosteroid (LABA/ICS).
• As ICS increases the risk for developing pneumonia, their primary choice is LABA/LAMA.

Group D

• The authors recommend initiating a LABA/LAMA combination because: LABA/LAMA combination was superior to LABA/ICS combination in preventing exacerbations and improving other patient reported outcomes in Group D patients.
• Group D patients are at higher risk for pneumonia when receiving ICS treatment.
• These patients may have a history and/or findings suggestive of asthma-COPD overlap and/or high blood eosinophil counts.
• The possibility of developing resistant organisms should be factored into the decision making.

End-of-life and palliative care

• Patients should be informed that should they become critically ill, they or their family members may need to decide whether a course of intensive care is likely to achieve their personal goals of care.
• Simple, structured conversations about these possible scenarios should be discussed while patients are in their stable state.

Vaccination

• Influenza vaccination is recommended for all patients with COPD.
• Pneumococcal vaccinations, PCV13 and PPSV23, are recommended for all patients > 65 years of age.
• The PPSV23 is also recommended for younger COPD patients with significant comorbid conditions including chronic heart or lung disease.

Ventilatory support

• NIV is occasionally used in patients with stable very severe COPD.
• NIV may be considered in a selected group of patients, particularly those with pronounced daytime hypercapnia and recent hospitalization, although contradictory evidence exists regarding its effectiveness.
• In selected patients with heterogeneous or homogenous emphysema and significant hyperinflation refractory to optimized medical care, surgical or bronchoscopic modes of lung volume reduction (e.g., endobronchial one-way valves or lung coils) may be considered.

Monitoring and Follow-Up

• Routine follow-up of COPD patients is essential.
• Symptoms, exacerbations and objective measures of airflow limitation should be monitored to determine when to modify management and to identify any complications and/or comorbidities that may develop.
• In order to adjust therapy appropriately as the disease progresses, each follow-up visit should include a discussion of the current therapeutic regimen.
• Symptoms that indicate worsening or development of another comorbid condition should be evaluated and treated.

Key Points

• The most common causes are respiratory tract infections.
• The goal for treatment of exacerbations is to minimize the negative impact of the current exacerbation and to prevent subsequent events.
• Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge.
• Severe exacerbations may be associated with acute respiratory failure.
• COPD often coexists with other diseases that may have a significant impact on prognosis.

Treatment Setting

• The goals of exacerbation treatment are to minimize the negative impact of the current exacerbation, and to prevent the development of subsequent events.
• More than 80% of exacerbations are managed on an outpatient basis with bronchodilators, corticosteroids, and antibiotics. [251] [252] [253].

Pharmacologic Treatment

• The most commonly used classes of medications for COPD exacerbations are bronchodilators, corticosteroids, and antibiotics.
• Systemic glucocorticoids in COPD exacerbations shorten recovery time and improve FEV 1 .

Respiratory Support

• Supplemental oxygen should be titrated to improve hypoxemia with a target saturation of 88-92%.
• Once oxygen is started, blood gases should be checked to ensure satisfactory oxygenation without carbon dioxide retention and/or worsening acidosis.
• Some patients require admission to the intensive care unit.
• Admission of patients with severe exacerbations to intermediate or special respiratory care units may be appropriate if adequate personnel skills and equipment exist to manage acute respiratory failure.

Noninvasive mechanical ventilation.

• NIV is preferred over invasive ventilation as the initial mode of ventilation to treat acute respiratory failure in patients hospitalized for acute exacerbations of COPD.
• Mortality and intubation rates are reduced by NIV.
• The indication for initiating invasive mechanical ventilation during an exacerbation includes failure of an initial trial of NIV.
• In patients who fail non-invasive ventilation as initial therapy and receive invasive ventilation as.

Hospital Discharge and Follow-Up

• Lack of spirometric assessment and arterial blood gas analysis have been associated with re-hospitalization and mortality.
• There is insufficient data that they influence readmission rates, short-term mortality 293, 294, 296, 297 or cost-effectiveness.
• An assessment of the presence and management of comorbidities should also be undertaken .

Ischemic heart disease

• There is an increased risk of myocardial damage in patients with concomitant ischemic heart disease who have an acute exacerbation of COPD.
• Patients who demonstrate abnormal cardiac troponins are at an increased risk of adverse outcomes including short-term (30 day) and long-term mortality.

Arrhythmias

• Cardiac arrhythmias are common in COPD and vice versa.
• Atrial fibrillation is frequent and directly associated with FEV 1 .
• Bronchodilators have been previously described as potentially pro-arrhythmic agents; 314, 315 however, evidence suggests an overall acceptable safety profile for long-acting beta 2 -agonists, 316 anticholinergic drugs (and inhaled corticosteroids).

Osteoporosis

• Osteoporosis is often associated with emphysema, 325, 326 decreased body mass index 327 and low fat-free mass.
• An association between inhaled corticosteroids and fractures has been found in pharmaco-epidemiological studies.
• Systemic corticosteroids significantly increase the risk of osteoporosis.

Metabolic Syndrome and Diabetes

• Metabolic syndrome and diabetes are more frequent in COPD and the latter is likely to affect prognosis.
• The prevalence of metabolic syndrome has been estimated to be more than 30%.

Education and self-management

• Education alone is not effective (Evidence C). Self-management intervention with communication with a health care professional improves health status and decreases hospitalizations and emergency department visits (Evidence B).
• Fatigue can be improved by self-management education, pulmonary rehabilitation, NIV should be the first mode of ventilation used in COPD patients with acute respiratory failure because it improves gas exchange, reduces the need for intubation, decreases hospitalization duration and improves survival (Evidence A). .
• Lung volume reduction surgery improves lung function, exercise capacity and quality of life in selected patients with upper-lobe emphysema and survival in a subset with upper lobe emphysema and low post rehabilitation exercise performance (Evidence A). .
• In selected patients with a large bulla surgical bullectomy may be considered (Evidence C). Onset of new physical signs (e.g., cyanosis, peripheral edema).

Figures

Table 2. Role of spirometry

Table 4. Anti-inflammatory therapy in stable COPD

Figure 4. Interventional bronchoscopic and surgical treatments for COPD

Table 6. Key points for the use of anti-inflammatory agents

Table 5. Key points for the use of bronchodilators

Full text

For Review Only
Global Strategy for th
e Diagnosis, Management, and
Prevention of Chronic Obstructive Lung Disease 2017
Report: GOLD Executive Summary
Journal:
American Journal of Respiratory And Critical Care Medicine
Manuscript ID
Blue-201701-0218PP
Manuscript Type:
PP - Pulmonary Perspective
Date Submitted by the Author:
26-Jan-2017
Complete List of Authors:
Vogelmeier, Claus; University of Marburg
Criner, Gerard; Lewis Katz School of Medicine at Temple University
Martinez, Fernando J; New York-Presbyterian Hospital/Weill Cornell Medical
Center
Anzueto, Antonio; University of Texas Health Science Center and South
Texas Veterans Health Care System
Barnes, Peter; National Heart & Lung Institute, Imperial College London,
Airway Disease Section,
Bourbeau, Jean; McGill University Health Centre, McGill University
Celli, Bartolome; Brigham and Women's Hospital,
Chen, Rongchang; State Key Lab for Respiratory Disease, Guangzhou
Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou
Medical University
Decramer, Marc; University of Leuven
Fabbri, Leonardo; University of Modena & Reggio Emilia
Frith, Peter; Flinders University Faculty of Medicine
Halpin, David; Royal Devon & Exeter Hospital
López Varela, M. Victorina ; Universidad de la República, Hospital Maciel
Nishimura, Masaharu; Hokkaido University School of Medicine
Roche, Nicolas; Hôpital Cochin (APHP), University Paris Descartes
Rodriguez-Roisin, Roberto; Thorax Institute, Hospital Clinic Universitat de
Barcelona
Sin, Don; St. Paul's Hospital, University of British Columbia
Singh, Dave; University of Manchester
Stockley, Robert; University Hospital
Vestbo, Jørgen; University of Manchester
Wedzicha, Jadwiga; Imperial College London, National Heart and Lung
Institute
Agusti, Alvar; Hospital Clínic, Universitat de Barcelona, Ciberes
Subject Category:
9.09 COPD: General < LUNG DISEASES
Keywords:
Diagnosis, Management and Prevention of COPD

For Review Only
Page 1 of 74

For Review Only
Global Strategy for the Diagnosis, Management, and Prevention of Chronic
Obstructive Lung Disease 2017 Report
GOLD Executive Summary
Claus F. Vogelmeier
1*
, Gerard J. Criner
2*
, Fernando J. Martinez
3*
, Antonio Anzueto
4
,
Peter J. Barnes
5
, Jean Bourbeau
6
, Bartolome R. Celli
7
, Rongchang Chen
8
, Marc
Decramer
9
, Leonardo M. Fabbri
10
, Peter Frith
11
, David M. G. Halpin
12
, M. Victorina
López Varela
13
, Masaharu Nishimura
14
, Nicolas Roche
15
, Roberto Rodriguez-Roisin
16
,
Don D. Sin
17
, Dave Singh
18
, Robert Stockley
19
, Jørgen Vestbo
18
, Jadwiga A.
Wedzicha
20
and Alvar Agusti
21
.
*These authors contributed equally to the manuscript
1
University of Marburg, Marburg, Germany, Member of the German Center for Lung
Research (DZL);
2
Lewis Katz School of Medicine at Temple University, Philadelphia,
Pennsylvania, USA;
3
New York-Presbyterian Hospital, Weill Cornell Medical Center,
New York, New York, USA;
4
University of Texas Health Science Center and South
Texas Veterans Health Care System, San Antonio, Texas, USA;
5
National Heart and
Lung Institute, Imperial College, London, United Kingdom;
6
McGill University Health
Centre, McGill University, Montreal, Canada;
7
Brigham and Women’s Hospital Boston,
Massachusetts, USA;
8
State Key Lab for Respiratory Disease, Guangzhou Institute of
Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University,
Guangzhou, PRC;
9
University of Leuven, Leuven, Belgium;
10
University of Modena &
Reggio Emilia, Modena, Italy;
11
Flinders University Faculty of Medicine, Bedford Park,
South Australia, Australia;
12
Royal Devon & Exeter Hospital, Exeter, UK;
13
Universidad
de la República, Hospital Maciel, Montevideo, Uruguay;
14
Hokkaido University School of
Medicine Sapporo, Japan;
15
Hôpital Cochin (APHP), University Paris Descartes, Paris,
France;
16
Thorax Institute, Hospital Clinic Universitat de Barcelona, Barcelona, Spain;
17
St. Paul's Hospital, University of British Columbia, Vancouver, Canada;
18
University of
Manchester, Manchester, UK;
19
University Hospital, Birmingham, UK;
20
Imperial College
London, London, UK;
21
Hospital Clínic, Universitat de Barcelona, Ciberes, Barcelona,
Spain.
For reprint requests, please contact Diane Gern at dgern@thoracic.org or 212-315-
6441.
Page 2 of 74

For Review Only
Abstract
This Executive Summary of the Global Strategy for the Diagnosis, Management, and
Prevention of COPD (GOLD) 2017 Report focuses primarily on the revised and novel
parts of the document. The most significant changes include: i) the assessment of
COPD has been refined to separate the spirometric assessment from symptom
evaluation. ABCD groups are now proposed to be derived exclusively from patient
symptoms and their history of exacerbations; ii) for each of the groups A to D,
escalation strategies for pharmacological treatments are proposed; iii) the concept of
de-escalation of therapy is introduced in the treatment assessment scheme; iv)
nonpharmacologic therapies are comprehensively presented and; v) the importance of
comorbid conditions in managing COPD is reviewed.
Page 3 of 74

For Review Only
CONTENTS
Introduction
Definition and Factors That Influence COPD Development and Progression
Key Points
Definition and Pathogenesis
Factors That Influence Disease Development and Progression
Diagnosis and Initial Assessment
Key Points
Diagnosis
Symptoms
Dyspnea
Cough
Sputum production
Wheezing and chest tightness
Additional features in severe disease
Medical History
Physical examination
Spirometry
Assessment
Classification of severity of airflow limitation
Assessment of symptoms
Choice of thresholds
Assessment of exacerbation risk
Blood eosinophil count
Assessment of concomitant chronic diseases (comorbidities)
Revised combined COPD assessment
Example
Alpha-1 antitrypsin deficiency
Additional investigations
Composite scores
Differential diagnoses
Other considerations
Prevention and Maintenance Therapy
Key Points
Smoking Cessation
Nicotine replacement products
Pharmacologic products
Smoking cessation programs
Vaccinations
Influenza vaccine and Pneumococcal vaccines
Pharmacologic Therapy for Stable COPD
Overview of medications
Bronchodilators
Beta
2
-agonists
Antimuscarinic drugs
Methylxanthines
Combination bronchodilator therapy
Page 4 of 74