The most recent update of the GesEPOC Spanish COPD guidelines recommends an integrated approach to classifying patients with chronic obstructive pulmonary disease (COPD) according to their level of risk, in order to make a multidimensional assessment in high-risk individuals.1

Multiple studies have shown that forced expiratory volume in 1 second (FEV1) is a good predictor of morbidity and mortality,2 although this parameter alone is not sufficient to correctly classify patients. For this reason, new composite indices have been created to improve the prognostic information provided by FEV1.3 The first version of GesEPOC, published in 2012, proposed an alternative to FEV1 in the form of a new classification with 5 severity (or risk) levels, based essentially on the BODE and BODEx indices. However, its use in clinical practice was found to be very low.4 For this reason, the new 2017 edition of GesEPOC responded to the need to simplify the risk stratification and proposed a new classification which is based on functional (percentage of FEV1 after bronchodilation) and clinical (dyspnea grade measured by the modified Medical Research Council [mMRC] and exacerbations) criteria.

We conducted an observational study of the cohort of patients being followed up by the dedicated COPD clinic of the respiratory medicine department the Hospital Universitario de La Princesa, Madrid (Spain). The primary objective of the study was to characterize these patients according to the new risk classification, and to evaluate the appropriateness of care and treatment based on the recommendations proposed by GesEPOC 2017.

We performed a descriptive statistical analysis (relative and absolute frequencies; means and standard deviations depending on the type of variable) using the SPSS statistical package version 22.0 (IBM, USA).

Our cohort comprised a total of 430 patients. Of these, 144 (33.5%) met the criteria for low risk and 286 (66.5%) were classified as high risk. In total, 57 (19.9%) of the high-risk population presented the 3 criteria, and 33 (11.5%) met a single criterion. The most common high-risk criterion was mMRC dyspnea grade ≥2, present in 76.2% of the patients. Twelve (4.2%) patients were classified as high risk due to presence of mMRC dyspnea grade ≥2 as a single criterion.

Demographic and clinical characteristics, and the distribution by clinical phenotype according to level of risk, are shown in Table 1. No statistically significant differences were found in our cohort between the 2 groups according to age, sex or comorbidities. All high-risk patients were classified according to their clinical phenotype, the exacerbator phenotype being the most common (50.3%) and the mixed phenotype the least common (8.7%), in line with findings from previous studies.5–7

High-risk patients presented a significantly higher number of exacerbations, more dyspnea, and worse lung function than low-risk individuals (p < 0.05), as was to be expected. These patients also had a higher level of severity according to the BODE and BODEx indices (4 ± 2.3 and 3.9 ± 1.8, respectively).

With regard to treatment by risk level, most high-risk patients were treated with triple therapy (long-acting muscarinic antagonist/long-acting ®-2 adrenoceptor agonist/inhaled corticosteroids [LAMA/LABA/ICS]), with no differences between exacerbators with chronic bronchitis vs. exacerbators with emphysema (66.1% vs. 67.1%), similar to reports from larger published series.8,9 A total of 62.4% of high-risk non-exacerbators were also receiving triple therapy. Furthermore, despite the fact that in low-risk patients the most commonly used option was dual bronchodilation, 27.1% of the patients were receiving triple therapy. The percentage of low-risk COPD patients in our series who are receiving triple therapy cannot be fully justified by the frequency of mixed phenotype (9.7% of patients). As observed in other studies, this high number must correspond to overtreated patients.10

With regard to non-pharmacological treatment, 61.2% of high-risk patients in our cohort were included in a pulmonary rehabilitation program, 46.9% had chronic domiciliary oxygen therapy, and 22.2% used portable oxygen therapy.

In terms of the diagnostic process, 94.4% of low-risk patients and 93.7% of high-risk patients underwent spirometry with bronchodilator challenge for diagnosis and arterial oxygen saturation was evaluated in all patients. In contrast, alpha 1-antitrypsin deficiency determination was not requested in the vast majority of patients (23.3% of the low-risk group and 25.9% of the high-risk group). With regard to other more specific complementary tests, a CT scan of the chest was performed in 99.6%, a walk test in 80.4%, lung volumes in 87.1%, and diffusing capacity in 81.5% of the high-risk patients. Diagnostic tests were performed in our patients according to the recommendations of the GesEPOC 2017 guidelines, except for alpha 1-antitrypsin deficiency screening.

One of the limitations of our study is that all patients were from a single hospital cohort, so the results cannot be applied to the general COPD population, which may have more comorbidities and other factors associated with high risk.

In conclusion, most of the patients in follow-up in our dedicated clinic are high-risk and present an exacerbator phenotype. Patients are managed in line with the recommendations proposed by GesEPOC 2017, although there are significant areas for improvement with respect to alpha 1-antitrypsin deficiency screening and adherence to the recommendations for drug treatment.