Chronic obstructive pulmonary disease (COPD) is the cause of considerable morbidity and mortality with the global burden of disease projected to increase even further in forthcoming years [1]. Although significant advances have been made in our understanding, assessment and management of COPD in the past decade, the heterogeneity of clinical features and variability in disease course continue to be only partially explained by currently available metrics. Hence, COPD subtype determination remains challenging. Until the late 1990s, COPD was defined by abnormal expiratory airflow [2, 3]. Although there was no consensus about a universal staging system, forced expiratory volume in 1 s (FEV1) alone was generally used to define disease severity [3]. FEV1 does capture many facets of disease severity and hence algorithms were proposed for the management of COPD, based on the reduction in FEV1 [3]. However, this approach is problematic in that not all aspects of the disease are adequately captured by FEV1. Furthermore, such algorithms were not globally implemented [2] and attention from the healthcare community, scientific societies and government officials for COPD was generally low. In 1997 the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was launched in order to raise worldwide awareness of COPD and improve prevention and treatment of the disease. In the first GOLD workshop summary report [4], COPD was defined as “a disease state characterized by airflow limitation that is not fully reversible and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases”. Furthermore, it stated that “symptoms, functional abnormalities and complications of COPD can all be explained on the basis of this underlying inflammation and the resulting pathology” [4]. A unidimensional classification of disease severity …
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