br Chronic obstructive pulmonary disease COPD remains a

Chronic obstructive pulmonary disease (COPD) remains a major public health problem. The was first published by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in 2001. A major revision was undertaken in 2011 and an update to it was published in February this year. The Chinese Society of Respiratory Disease recently released new Chinese COPD guidelines, which recommend that the same strategy is used in China. However, whether this new system proves to be an improvement on the old system and whether it is applicable in China remains controversial and needs further research. Many differences exist between China and the developed countries that most of the GOLD committee members come from. 4·3 million people in China have COPD, and the disease prevalence is significantly higher in rural (8·8%) than in urban areas (7·8%; p=0·007). 36·4% of practising Chinese doctors work at basic medical facilities (including angiotensin ii health service centres, small rural hospitals, village health rooms, clinics, and nurses\' stations). The educational level of these doctors is worrying. Of licensed doctors, only 8·3% have a post-graduate degree and 43·6% have a bachelor\'s degree. Thus, nearly half of all doctors in China have quite a low level of education, and the situation for licensed assistant doctors is even worse. Use of the GOLD criteria in China encounters several problems, as outlined below. The assessment of symptoms in patients with COPD is based on either the modified Medical Research Council (mMRC) or the COPD Assessment Test score. In GOLD 2013, the Clinical COPD Questionnaire is also introduced. In clinical practice in China, 40–80 patients are seen per doctor per day, without enough nurses or physician assistants to help. Therefore, whichever is the easiest method to assess symptoms is judged to be the best. In one of our studies we enrolled 6437 patients in 329 hospitals across China and found that the COPD Assessment Test score was moderately correlated with mMRC dyspnoea grade (r=0·579, p<0·001). The most practical approach is for physicians to ask only one question—“do you feel breathless when walking?”—and quickly obtain the mMRC score. Therefore, use of only mMRC might be suitable for Chinese clinical practice. Spirometry is needed to diagnose COPD in the new GOLD 2011 criteria and spirometric tests are always important in the assessment of the disease. However, spirometry is not correctly or widely used in China. He and colleagues reported that only 50% of patients with COPD had ever had spirometry tests in tertiary hospitals, and only 18% had in primary or secondary hospitals. In our epidemiological survey in a rural area of Beijing, none of the 148 patients with COPD had ever undergone spirometry. This situation is due to inadequate physician knowledge about the disease and a scarcity of equipment in lower-level hospitals. A solution could be to use different methods in different hospitals. Although the GOLD criteria are suitable for use in tertiary hospitals, other methods such as peak expiratory flow rate could be used instead in primary or secondary hospitals, since their sensitivity and specificity are quite good. The risk of exacerbation can be assessed in several ways: symptoms, use of medication, and admission to hospital. However, several questions remain to be answered in Chinese clinical practice. For example, the time of an acute exacerbation is often inaccurate because many patients have a poor understanding of the disease, and they might be unwilling or unable to write a COPD diary. Changes in medication, such as use of short-acting β2-agonists, antibiotics, or oral corticosteroids, might be strongly affected by the knowledge of the physicians and the financial situation of the patients. In our study, none of the stable patients with COPD took inhalers regularly or as needed. During acute exacerbations, only 6·8% took theophylline and 6·8% antibiotics. Another Chinese study reported similar results. However, in China, patients can obtain antibiotics easily. Many people keep antibiotics in reserve at home and they tend to show a preference for these drugs. Thus, use of antibiotics does not always indicate an acute exacerbation. Finally, the indication of hospital admission varies in different hospitals, and is affected by socioeconomic factors, the health system, and policy.