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Rebuttal from Dr. Kerstjens

Dr. Calverley admits to the fact that the cut-points (the core of the classification) are not evidence-based. We will probably agree that this is due to lack of available knowledge. I personally hold great expectation that by writing down these cut-points and this classification scheme, pulmonary science will accelerate its pace toward knowledge (evidence). Researchers, both those opposed to the scheme and those in favor of the scheme, should and will start to test, and sanction or improve the classification. The impact of GOLD is large enough to bring this acceleration forward, and we urgently need the data.

Dr. Calverley makes no mention of how this GOLD classification scheme will advance our understanding of pathophysiology. For a good reason: a scheme based solely on the FEV₁ just will not. We both refer to newer attempts at making classification schemes that incorporate up to four parameters of this multi-dimensional complex disease rather than solely the FEV₁ (1).

Where we seem to differ is on the importance attributed to symptoms in the diagnosis of COPD in the GOLD guideline. It worries me deeply that GOLD explicitly states (classification Table 1–2, www.goldcopd.com) that stages I, II, and III can come with or without chronic symptoms. Yes, it is true that the level of symptomatology can vary enormously between patients, even with more advanced decrements in FEV₁. If we are, however, to make a broad public of physicians and laymen aware of the enormous ground swell of COPD that will reach us by 2020, (2) we also need to herald the symptoms that should make one aware of this disease.

In summary, although the GOLD classification scheme has not yet advanced our understanding of COPD, I think there is every reason to believe it will in the future. Even if that is achieved only through provoking research.

REFERENCES

1. Celli BR, Cote CG, Marin JM, Casanova C, Montes DO, Mendez RA, Pinto PV, Cabral HJ. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004;350:1005–1012.[Abstract/Free Full Text]
2. Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet 1997;349:1498–1504.[CrossRef][Medline]

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