Deciphering the new global initiative for chronic obstructive lung disease (GOLD) guideline

Major research into molecular mechanisms and recently performed large-scale clinical studies in COPD have led to important insights into the pathogenesis and the clinical course of COPD. Based on these, the new GOLD guide has been completely revised. Certain pillars of management e. g. smoking cessation, pulmonary rehabilitation, and identifying and managing co-morbidities have been reinforced. The major change is the move away from the old staging system (which was more generalized and based largely on lung function deficit) towards the categorization of patients into 4 groups designated A, B, C, and D using three composite measures. These measures quantify the severity of lung function impairment, the degree of breathlessness, and the history of exacerbations. They now allow for a more individualized approach based on symptoms and future risk of adverse events and exacerbations. Mild degrees of dyspnea and lung function impairment and occasional exacerbations place subjects in the low-risk categories (A&B). More severe dyspnea and lung function impairment and a history of exacerbations >= 2 per year would lead to the categorization of higher risk (C&D). Low-risk patients are managed with bronchodilator therapies but high-risk patients are best managed with long-acting bronchodilators alone or a combination of bronchodilator classes, with or without inhaled corticosteroids. A novel phosphodiesterase inhibitor, roflumilast, is also an add-on alternative in high-risk patients. Utilizing these strategies will allow for improved clinical outcomes with respect to symptom relief and quality of life and additionally, in high-risk groups, reduce the chances of disease progression, exacerbations, and possible mortality.