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      2011 GOLD Stages of COPD: Transitions, Predictor Factors and Comparison with 2017 GOLD Stages

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          Despite wide use of the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) 2011, little is known about between-stage transitions and what factors predict worsening transitions in patients with chronic obstructive pulmonary disease (COPD).


          To investigate the transition frequency between GOLD 2011 stages among patients with stable COPD over a 2-year follow-up, to identify potential non-pulmonary predictor factors for worsening transitions, and to compare transition frequencies between GOLD 2011 stages and the new GOLD 2017 stages.

          Patients and Methods

          We prospectively included 137 patients with stable COPD (mean age, 66.9 ± 8.3 years). GOLD 2011 and GOLD 2017 stages were measured at baseline, 1-year follow-up, and 2-year follow-up. To evaluate non-pulmonary variables as potential predictors of worsening transitions, we used regression models adjusted for sociodemographic, clinical, and pulmonary variables using generalized estimating equations.


          The study period included 246 opportunities for transition, and 39 worsening transitions occurred within GOLD 2011 stages. Predictors of worsening transitions included BODE index (OR, 1.20; 95% CI, 1.00–1.44), quadriceps strength (OR, 0.87; 95% CI, 0.76–0.99), and limited mobility activities (OR, 1.02; 95% CI, 1.00–1.05). The frequency of worsening transitions for stages B and C differed between GOLD 2011 and GOLD 2017. Stages A and D were the most stable in both classifications.


          Non-pulmonary factors predicted worsening transitions among the GOLD 2011 stages of COPD severity. The choice of GOLD 2011 versus GOLD 2017 may influence transition identification, especially for stages B and C.

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          Most cited references 20

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          The COPD assessment test (CAT): response to pulmonary rehabilitation. A multicentre, prospective study.

          The COPD (chronic obstructive pulmonary disease) assessment test (CAT) is a recently introduced, simple to use patient-completed quality of life instrument that contains eight questions covering the impact of symptoms in COPD. It is not known how the CAT score performs in the context of clinical pulmonary rehabilitation (PR) programmes or what the minimum clinically important difference is. The introduction of the CAT score as an outcome measure was prospectively studied by PR programmes across London. It was used alongside other measures including the St George's Respiratory Questionnaire, the Chronic Respiratory Disease Questionnaire, the Clinical COPD Questionnaire, the Hospital Anxiety and Depression score, the Medical Research Council (MRC) dyspnoea score and a range of different walking tests. Patients completed a 5-point anchor question used to assess overall response to PR from 'I feel much better' to 'I feel much worse'. Data were available for 261 patients with COPD participating in seven programmes: mean (SD) age 69.0 (9.0) years, forced expiratory volume in 1 s (FEV(1)) 51.1 (18.7) % predicted, MRC score 3.2 (1.0). Mean change in CAT score after PR was 2.9 (5.6) points, improving by 3.8 (6.1) points in those scoring 'much better' (n=162), and by 1.3(4.5) in those who felt 'a little better' (n=88) (p=0.002). Only eight individuals reported no difference after PR and three reported feeling 'a little worse', so comparison with these smaller groups was not possible. The CAT score is simple to implement as an outcome measure, it improves in response to PR and can distinguish categories of response.
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            A validation study of the hospital anxiety and depression scale (HADS) in a Spanish population

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              Randomized controlled trial of pulmonary rehabilitation in severe chronic obstructive pulmonary disease patients, stratified with the MRC dyspnoea scale.

              This study tested the hypothesis that severity of respiratory disability may affect the outcome of pulmonary rehabilitation. In this randomized, controlled study, 126 patients with chronic obstructive pulmonary disease (COPD) were stratified for dyspnoea using the Medical Research Council (MRC) dyspnoea score into MRC3/4 (Moderate) (n=66) and MRC 5 (Severe) dyspnoeic (n=60) groups. The patients were randomly assigned to an eight week programme of either exercise plus education (Exercise group) or education (Control group). Education and exercise programmes for the moderately dyspnoeic patients were carried out in a hospital outpatient setting. Severely dyspnoeic patients were all treated at home. Those in the Exercise group received an individualized training programme. There was a significant improvement in shuttle walking distance in the moderate dyspnoeic group, who received exercise training; baseline (mean+/-SEM) 191+/-22 m, post-rehabilitation 279+/-22 m (p<0.001). There was no improvement in exercise performance in the severely dyspnoeic patients receiving exercise. Neither group of control patients improved. Health status, assessed by the Total Chronic Respiratory Disease Questionnaire score, increased in the moderately dyspnoeic patients receiving exercise from 80+/-18 to 95+/-17 (p<0.0001) after rehabilitation. Much smaller changes were seen in the other three groups. Improvement in exercise performance and health status in patients with chronic obstructive pulmonary disease after an exercise programme depends on the initial degree of dyspnoea.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of Chronic Obstructive Pulmonary Disease
                30 June 2020
                : 15
                : 1519-1527
                [1 ]Division of Pneumology, Hospital General Universitario Morales Meseguer , Murcia, Spain
                [2 ]Department of Internal Medicine, University of Murcia , Murcia, Spain
                [3 ]Research Group Fisioterapia y Discapacidad, Instituto Murciano de Investigación Biosanitaria-Virgen de la Arrixaca (IMIB-Arrixaca) , El Palmar, Murcia, Spain
                [4 ]Department of Physical Therapy, University of Murcia , Murcia, Spain
                [5 ]Department of Physical Therapy, EUSES University School, University of Girona , Girona, Spain
                Author notes
                Correspondence: Joaquina Montilla-Herrador Department of Physical Therapy, University of Murcia, Campus de Espinardo , Murcia30100, SpainTel +34868887534 Email
                © 2020 Bernabeu-Mora et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (

                Page count
                Figures: 3, Tables: 3, References: 28, Pages: 9
                Original Research

                Respiratory medicine

                gold, quadriceps strength, bode, mobility activities, copd exacerbations


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