Global Initiative for ChronicObstructiveL ungD isease
GLOBAL STRATEGY FOR THE DIAGNOSIS,
 
MANAGEMENT, AND PREVENTION OF
 
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
 
201
9
 REPORT
 
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GLOBAL INITIATIVE FOR
CHRONIC OBSTRUCTIVE LUNG DISEASE
GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (2019 REPORT) 
© 2019 Global Initiative for Chronic Obstructive Lung Disease, Inc.
 
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GOLD BOARD OF DIRECTORS (2018)
 
GOLD SCIENCE COMMITTEE
*
 (2018)
 
 Alvar Agusti, MD,
Chair 
 Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes 
Barcelona, Spain
 Bartolome R. Celli, MD
Brigham and Women’s Hospital
Boston,
 
Massachusetts, USA
 Rongchang Chen, MD Guangzhou Institute of Respiratory Disease 
Guangzhou, PRC
 Gerard Criner, MD Temple University School of Medicine 
Philadelphia, Pennsylvania, USA
 Peter Frith, MD Flinders University
 Adelaide,
 
 Australia
 David Halpin, MD Royal Devon and Exeter Hospital 
Devon, UK
 M. Victorina López Varela, MD Universidad de la República
Montevideo,
 
Uruguay
 Masaharu Nishimura, MD (retired May, 2018) Hokkaido University School of Medicine
Sapporo, Japan
Sundeep Salvi, MD Chest Research Foundation
Pune, India
Claus Vogelmeier, MD University of Marburg 
Marburg, Germany
Claus Vogelmeier, MD,
Chair 
 University of Marburg 
Marburg, Germany
  Alvar Agusti, MD Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes 
Barcelona, Spain
  Antonio Anzueto, MD University of Texas Health Science Center  
San Antonio, Texas, USA
 Peter Barnes, MD National Heart and Lung Institute 
London, United Kingdom
 Jean Bourbeau, MD McGill University Health Centre 
Montreal, Canada
Gerard Criner, MD Temple University School of Medicine 
Philadelphia, Pennsylvania, USA
 Peter Frith, MD Repatriation General Hospital
 Adelaide,
 
 Australia
 David Halpin, MD Royal Devon and Exeter Hospital
Devon, United Kingdom
MeiLan Han, MD MS University of Michigan
  Ann Arbor, MI, USA
Fernando J. Martinez, MD MS New York-Presbyterian Hospital/ Weill Cornell Medical Center  
New York, NY, USA 
 Alberto Papi, MD University of Ferrara
Ferrara, Italy
Ian Pavord, MA DM University of Oxford
Oxford, UK
Nicolas Roche, MD University Paris Descartes Hôpital Cochin APHP 
Paris, France
 Donald Sin, MD
St. Paul’s Hospital, University of
British Columbia
Vancouver, Canada
 Dave Singh, MD University of Manchester
Manchester, UK
 Robert Stockley, MD University Hospital
Birmingham, UK
 Jørgen Vestbo, MD University of Manchester  
Manchester, England, UK
 Jadwiga A. Wedzicha, MD Imperial College London
London, UK
M. Victorina López Varela, MD Universidad de la República Hospital Maciel
Montevideo, Uruguay
GOLD PROGRAM DIRECTOR 
Rebecca Decker, MSJ
 
Fontana, Wisconsin, USA
EDITORIAL ASSISTANCE
Ruth Hadfield, PhD,
Sydney, Australia
 Michael Hess, RRT RPFT,
Michigan, USA
 
*Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org
 
 
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GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF COPD (2019)
 
GOLD ASSEMBLY
 ARGENTINA
 Dr Eduardo A. Schiavi Buenos Aires, Argentina
AUSTRALIA
 Peter Frith, MD Adelaide, South Australia, Australia
AUSTRIA
 Dr Otto Chris Burghuber
BANGLADESH
 Prof Md Mostafizur Rahman Dhaka, Bangladesh Dr Kazi S. Bennoor Dhaka, Bangladesh
BRAZIL
 Aquiles Camelier, MD Sao Paulo, Brazil Fernando Lundgren, MD
CANADA
 Dr Dennis E. O
Donnell Kingston, Ontario, Canada
CHILE
 Dr Manuel Barros
CHINA
 Jiangtao Lin, MD Beijing, China Fu-Qiang Wen, MD, PhD Chengdu, Sichuan, China Nan-Shan Zhong, MD Guangzhou, China
COLOMBIA
 Alejandro Casas, MD Vice-Director, COPD Department Latin American Thoracic Society
CROATIA
 Neven Miculinic, MD Zagreb, Croatia
CZECH REPUBLIC
 Stanislav Kos, MD, PhD, FCCP Czech Civic Association Against Lung Diseases Pilsen, Czech Republic
DOMINICAN REPUBLIC
 Dr Eduardo Gautreau de Windt Provincia Santo Domingo, Dominican Republic
EGYPT
 Hisham Tarraf, MD Cairo, Egypt
EL SALVADOR
 Dr Victor Castro Gòmez San Salvador, El Salvador
FRANCE
 Gaetan Deslée, MD Hôpital Maison Blanche Reims, France
GEORGIA
 Maia Gotua, MD, PhD Tbilisi, Georgia
HONG KONG CHINA
 David S.C. Hui, MD Shatin, N.T. Hong Kong
INDONESIA
 Professor Faisal Yunus
IRAN
 Dr Masjedi Mohammad Reza Tehran, Iran Mohammad Ashkan Moslehi, MD Shiraz, Iran
IRELAND
 Timothy J. McDonnell, MD Dublin, Ireland
ISRAEL
 Zvi G. Fridlender, MD, MSc Jerusalem, Israel
ITALY
 Professor Lorenzo Corbetta Florence, Italy
JAPAN
 Takahide Nagase, MD Tokyo, Japan Michiaki Mishima, MD Kyoto, Japan
JORDAN
 Haytham El-Khushman Amman, Jordan
KAZAKHSTAN
 Damilya Nugmanova, MD, PhD, DSci Almaty, Kazakhstan
KOREA
 Yeon-Mok Oh, MD Seoul, South Korea
KUWAIT
 Professor Mousa Khadadah Kuwait University
KYRGYZSTAN
 Talant Sooronbaev, MD Bishkek, Kyrgyzstan
MALTA
 Prof Joseph M Cacciottolo Pieta, Malta
LEBANON
Mirna Waked, MD Beirut, Lebanon
MOLDOVA
 Alexandru Corlateanu, MD, PhD ERS National Delegate Republic of Moldova
MONGOLIA
 Dr Oyunchimeg Chair of International Cooperation
NORWAY
 Rune Nielsen, MD Bergen, Norway
PAKISTAN
 Professor Javaid Khan Karachi, Pakistan Dr Mohammad Osman Yusuf Islamabad, Pakistan
PHILIPPINES
 Teresita S. deGuia, MD Quezon City, Philippines
POLAND
 Ewa Nizankowska-Mogilnicka,MD,PhD, Krakow, Poland Pawel
Śliwiński
 Warsaw, Poland Paul Kuca, MD Warsaw, Poland
 ROMANIA
 Florin Mihaltan, MD Bucharest, Romania Ruxandra Ulmeanu, MD Bucharest, Romania
RUSSIA
 Alexander Chuchalin, MD Moscow, Russia
SINGAPORE
 Kian-Chung Ong, MD Wan-Cheng Tan, MD, Chair, Asian Pacific COPD Roundtable
SLOVAK REPUBLIC
 Ruzena Tkacova, MD PhD Kosice, Slovakia
SPAIN
 Dr Patricia Sobradillo
SYRIA
 Yousser Mohammad, MD Lattakia, Syria
TURKEY
 Prof Dr. Hakan Gunen Malatya, Turkey Nurdan Kokturk, MD Ankara, Turkey
URUGUAY
 Mará Victorina López, MD Montevideo, Uruguay
VENEZUELA
 Maria Montes de Oca, MD Caracas, Venezuela
VIETNAM
 Sy Duong-Quy, MD, PhD, FCCP Lam Dong Medical College, Vietnam Ngo Quy Chau, MD, PhD Hanoi, Vietnam Le Thi Tuyet Lan, MD, PhD Ho Chi Minh City, Vietnam
 
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PREFACE
In 2011, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) released a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD. It recommended a major revision in the management strategy for COPD that was first presented in the srcinal 2001 document. Reports released in January 2013, January 2014, January 2015, January 2016, January 2017 and January 2018 were based on updated scientific literature published since the completion of the 2011 document but maintain the same treatment paradigm. The 2015 update added an Appendix on Asthma COPD Overlap Syndrome, material prepared jointly by the GOLD and GINA Science Committees.
The assessment of COPD proposed by GOLD has been based on the patient’s level of symptoms, future
risk of exacerbations, the extent of airflow limitation, the spirometric abnormality, and the
identification of comorbidities. The “ABCD” assessment tool of the 2011 GOLD update was a major
advance from the simple spirometric grading system of the earlier versions of GOLD because it incorporated multimodality assessment, symptom burden and highlighted the importance of exacerbation prevention in the management of COPD. However, there were some important limitations to this scheme. The ABCD assessment tool performed no better than spirometric grades for mortality prediction or other important health outcomes. To address these and other concerns (while at the same time maintaining consistency and simplicity for the practicing clinician), a refinement of the ABCD assessment tool was proposed in the 2017 GOLD Report that separates
spirometric grades from the “ABCD” groups. Thus, ABCD groups
and their associated implications for pharmacotherapy recommendations will be derived exclusively from patient symptoms and their history of exacerbations. The separation of airflow limitation from clinical parameters makes it clearer what is being evaluated and ranked. This revised assessment tool acknowledges the limitations of FEV
1
 in influencing some therapeutic decisions for individualized patient care and highlights the importance of patient symptoms and exacerbation risks in patients with COPD. Spirometry remains key in the diagnosis, prognostication and treatment with non-pharmacological therapies. The GOLD report has been used worldwide as a
“strategy document” for health
care professionals to use as a tool to implement effective management programs based on local healthcare systems. The ABCD assessment tool has been used by many to structure their assessment of COPD symptom burden and create treatment plans. The 2017 revision introduced a refinement of the ABCD system by separating spirometric evaluation from analysis of symptoms/exacerbation history with the recommendations for pharmacotherapy being based primarily on the patient needs (symptom reduction and/or exacerbation prevention). Following feedback from GOLD report users, the committee identified there was some misinterpretation regarding the use of the ABCD system. Therefore, in the 2019 revision initial treatment (based on ABCD) is separated from follow-up
treatment (based on the patient’
s major treatable trait(s) and the currently used drug(s)). In addition, we introduce the blood eosinophil count as a biomarker for estimating the efficacy of inhaled corticosteroids for the prevention of exacerbations. GOLD has been fortunate to have a network of international distinguished health professionals from multiple disciplines. Many of these experts have initiated investigations of the causes and prevalence
of 155