Guidelines presents Guideline Essentials, a new type of summary that:
- features expert clinician commentary on the guidance
- adds context through comparisons with other guidelines
- makes lengthy guidelines easier to navigate for healthcare professionals.
OverviewIn 2023, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) issued an update to its guidance, Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.
This Guidelines overview for primary care provides a summary of the strategy's key recommendations on the diagnosis, management, and prevention of chronic obstructive pulmonary disease (COPD), and examines the advice with reference to other guidance on the management of COPD (see Table 1).
Table 1: UK Guidance Landscape for the Management of Clinical Management of COPD,
|Guideline||Topics Covered||Last Updated|
|Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2023 report)||Definition and overview; diagnosis and assessment; prevention and maintenance therapy; management of stable COPD; management of exacerbations; COPD and comorbidities; COPD and COVID-19||2023|
|All Wales COPD management and prescribing guideline||Assessment; diagnosis; referral; prescribing; review||2021|
|NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management||Diagnosing COPD; managing stable COPD; managing exacerbations of COPD||2019|
|COPD=chronic obstructive pulmonary disease; NG=NICE Guideline|
Please refer to the full GOLD strategy for the complete recommendations, methodology, references, background information, and description of levels of evidence.
Reflecting on your Learnings
Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.
|Key Takeaways from the Guideline|
Context for Primary Care
The chronic respiratory condition COPD:
- has been redefined by GOLD in the 2023 report as 'a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnoea, cough, sputum production, exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive airflow obstruction'
- see Box 1 for information on how the definition of COPD has evolved
- is underpinned by a complex interplay between risk factors, which include
- exposure to environmental triggers (including, but not limited to, tobacco smoke and air pollution)
- genetic predisposition
- development of precursor conditions
- congenital abnormalities
- atypical lung ageing
- commonly presents with comorbid conditions that can impact outcomes
- can have a poor prognosis without accurate diagnosis
- can be both prevented and treated.
|Box 1: The Evolving Definition of COPD,|
'[COPD] is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production, exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive airflow obstruction.'
'[COPD] is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases and influenced by host factors including abnormal lung development.'
'The "working definition of COPD" has been deleted, because it was not based on an evidence review and it was unclear whether the thresholds it used were correct and up to date.'
COPD=chronic obstructive pulmonary disease; GOLD=Global Initiative for Chronic Obstructive Lung Disease
COPD Global Burden
- is responsible for significant morbidity and mortality
- is among the three leading causes of death, causing an estimated 3 million deaths worldwide each year
- is due to causes other than tobacco smoking in up to 30% of cases in high-income countries
- has a high mortality rate in less affluent countries
- is predicted to rise in prevalence in future as a result of factors such as:
- the increasing average age of the population
- the effects of unmitigated risk factors.
Alterations to Lung Architecture and Function in COPD
Pathological Changes Underlying COPD
COPD can cause both structural and inflammatory changes in the:
- trachea, bronchi, bronchioles, and alveoli
- pulmonary parenchyma
- vasculature of the lung.
- decreased airway patency, an inability to fully empty the lungs on exhalation, and hyperinflation of the lungs
- abnormal gas exchange in the lungs, hypoxaemia and/or hypercapnia, and respiratory failure and acidosis
- circulatory abnormalities, elevated pulmonary blood pressure, and cardiac consequences such as right-ventricular hypertrophy and heart failure.
Common Symptoms of COPD
- Dyspnoea, which is progressive and worse on exertion
- Cough, which may progress from intermittent to chronic, and may or may not be productive
- Sputum production, which occurs in up to 30% of patients
- Recurrent lower respiratory tract infections.
Less Specific Symptoms of COPD
- Wheezing, which may be inspiratory and/or expiratory
- Chest tightness following exertion, which is muscular in nature
- Weight loss, which can also be a red flag for other conditions such as lung cancer
- Depression and anxiety, which may negatively impact outcomes.
Comparison with Symptoms in UK-specific GuidanceSee Table 2 for a comparison of core symptoms of COPD listed in other published UK guidance.
Table 2: Comparison of Core Symptoms of COPD in GOLD and UK Guidelines,
|GOLD (2023)||AWMSG (2021)||NICE (2019)|
|GOLD=Global Initiative for Chronic Obstructive Lung Disease; COPD=chronic obstructive pulmonary disease; AWMSG=All Wales Medicines Strategy Group|
Symptom FeaturesThe symptoms of COPD:
- may change from day to day
- may occur in the absence of airflow obstruction, and vice versa
- are not in themselves diagnostic, but the presence of multiple symptoms raises the likelihood of COPD
- can be difficult to distinguish from the symptoms of asthma.
Diagnosis in Primary Care
According to GOLD, the following findings confirm a diagnosis of COPD:
- the presence of dyspnoea, chronic cough/sputum production, a history of recurrent lower respiratory infections and/or risk factors for the condition, and
- on forced spirometry, airflow limitation that is not fully reversible and yields a postbronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio of <0.7.
|Box 2: Comparison of Diagnostic Criteria for COPD in Other UK Guidelines,|
The AWMSG guidance states that a diagnosis of COPD can be made when 'post-bronchodilator FEV1/FVC ratio <LLN.'
In NG115, diagnosis is based on symptoms and signs and supported by spirometry, and 'an FEV1/FVC ratio below 0.7' is used to prompt additional investigations in older people without typical symptoms of COPD.
COPD=chronic obstructive pulmonary disease; AWMSG=All Wales Medicines Strategy Group; FEV1=forced expiratory volume in 1 second; FVC=forced vital capacity; LLN=lower limit of normal; NG=NICE Guideline
Potential differential diagnoses for COPD include:
- congestive heart failure
- obliterative or diffuse bronchiolitis.
|Box 3: Comparison of Differential Diagnoses of COPD in Other UK Guidelines,|
Categorisation of Disease Severity
GOLD grades the severity of airflow limitation in people with COPD as follows:
- mild (GOLD 1)—FEV1 is ≥80% of the predicted value
- moderate (GOLD 2)—FEV1 is 50–79% of the predicted value
- severe (GOLD 3)—FEV1 is 30–49% of the predicted value
- very severe (GOLD 4)—FEV1 is <30% of the predicted value.
- Group A—Modified Medical Research Council (mMRC) Score 0–1; COPD Assessment Test™ (CAT™) Score <10; 0 or 1 moderate exacerbations without hospital admission
- Group B—mMRC Score ≥2; CAT™ Score ≥10; 0 or 1 moderate exacerbations without hospital admission
- Group E—≥2 moderate exacerbations without hospital admission or ≥1 severe exacerbation necessitating hospital admission.
To compare the 2023 'ABE' system with the 2022 'ABCD' system, see Table 3.
Table 3: Comparison of the GOLD 2022 'ABCD' and 2023 'ABE' Classification Systems
|2022 GOLD 'ABCD' Classification System||2023 GOLD 'ABE' Classification System|
|GOLD=Global Initiative for Chronic Obstructive Lung Disease; mMRC=Modified Medical Research Council Dyspnoea Scale; CAT™=COPD Assessment Test™|
Assessment of Suspected COPDAssessment of a patient with suspected COPD is undertaken to inform treatment, and should consider the:
- degree of airflow obstruction
- type and burden of symptoms
- history of exacerbations in the preceding 12 months
- likelihood of future adverse events
- presence of comorbidities.
- risk factors, occupation, relevant past medical events (including in early life), and family history of respiratory conditions, including COPD
- symptoms, exacerbations, hospitalisation, comorbidities, and effects on quality of life
- sources of support and opportunities to mitigate risk.
- spirometry is the most useful method of evaluating airflow limitation but should not be used in isolation to make a diagnosis of COPD
- validated questionnaires—such as the mMRC Dyspnoea Scale and the CAT™, among others—should be used to assess symptoms
- exacerbation risk should be predicted based on exacerbation history
- comorbidities should be identified.
When the correlation between airway limitation and patient-reported symptoms is poor, clinicians may wish to investigate further and/or eliminate alternative diagnoses by performing or referring patients for:
- physiological tests, such as lung volume tests (body plethysmography, helium dilution lung volume measurement), lung function tests (diffusing capacity of the lungs for carbon monoxide), blood gas analyses (pulse oximetry and arterial blood gas measurements), and exercise tests
- imaging studies, such as chest X-ray, computed tomography
- genetic testing for alpha-1 antitrypsin deficiency.
|Box 4: Comparison of First-line and Additional Investigations for COPD in Other UK Guidelines,|
For information on multidimensional questionnaires, additional investigations, and treatable traits, refer to the full strategy report.
Maintenance and Preventative Approaches for COPD
Maintenance and prevention strategies for COPD aim to:
- reduce symptoms
- decrease exacerbation risk
- limit risk factor exposure
- delay disease progression
- increase exercise capacity
- improve health status.
- support and pharmacotherapy to stop smoking, if applicable
- note: the safety and efficacy of e-cigarettes are unproven for this indication
- recommended vaccinations for:
- pertussis, tetanus, and diphtheria in those who did not receive routine childhood immunisations
- pulmonary rehabilitation, comprising
- exercise training
- patient education
- self-management support.
Management of Stable COPD in Primary Care
The management of stable COPD aims to relieve symptoms, reduce exacerbation frequency and severity, and improve health and functioning, and consists of:
- individualised treatment informed by disease severity and exacerbation risk
- nonpharmacological interventions
- pharmacological interventions
- tailored inhaler device choice and training in inhaler technique, if applicable
- assessment of adherence to treatment and inhaler technique
- evaluation of the patient's response to interventions and need for treatment escalation.
- adverse effects.
Pharmacological Therapies for COPDPharmacological treatments for COPD act to increase expiratory flow; therapeutic options include:
- short-acting beta2 agonists (SABAs)
- long-acting beta2 agonists (LABAs)
- antimuscarinic (anticholinergic) agents:
- short-acting muscarinic antagonists (SAMAs)
- long-acting muscarinic antagonists (LAMAs)
- anti-inflammatory drugs
- inhaled corticosteroids (ICSs)
- oral glucocorticoids
- phosphodiesterase-4 (PDE4) inhibitors
- mucolytic agents.
Initial PharmacotherapyAccording to GOLD, the basic principles of initial pharmacological treatment of COPD are as follows:
- in general, long-acting therapies are preferable to short-acting therapies
- inhaled bronchodilators are favoured over oral bronchodilators
- a LABA+LAMA combination is the gold standard; if escalation is required, a second long-acting bronchodilator should be added
- except when alternative bronchodilators for long-term treatment are unavailable, theophylline is not recommended
- a LABA+ICS combination is not endorsed for COPD
- an ICS should always form part of treatment for patients with COPD and symptoms of asthma
- the addition of a PDE4 inhibitor may be appropriate in patients with severe or very severe airway obstruction, chronic bronchitis, and exacerbations
- the addition of macrolide antibiotics may be appropriate in patients with exacerbations, particularly ex-smokers.
- a blood eosinophil count ≥300 cells/mcl strongly favours the addition of an ICS
- when blood eosinophil count is <100 cells/mcl, an ICS offers little additional benefit.
- Group A—bronchodilator therapy
- Group B—dual therapy consisting of LABA+LAMA, combined in a single device if possible
- Group E—dual therapy consisting of LABA+LAMA, combined in a single device if possible, with the addition of an ICS if blood eosinophil count is ≥300 cells/mcl.
- a rescue SABA should be prescribed for immediate symptomatic relief.
To compare these treatment recommendations with those of other guidelines on COPD, see Box 5.
|Box 5: Initial Pharmacological Treatment Recommendations for COPD in Other UK Guidelines,|
Managing Stable COPD
SABAs and SAMAs
Inhaled Combination Therapy
AWMSG=All Wales Medicines Strategy Group; COPD=chronic obstructive pulmonary disease; LABA=long-acting beta2 agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid; SABA=short-acting beta2 agonist; SAMA=short-acting muscarinic antagonist; PDE4=phosphodiesterase-4
Follow-up pharmacological therapy comprises review of symptoms and exacerbation risk, assessment of device technique and compliance, and adjustment of therapy, and is dependent on response to treatment as follows:
- if response to treatment is adequate, treatment should continue unchanged
- if response to treatment is inadequate
- assess adherence and confirm inhaler technique
- check and address any relevant comorbidities
- if response to treatment continues to be inadequate, adapt treatment to target treatable traits:
- dyspnoea—switch device or agent, add or escalate treatments, and/or investigate alternate causes
- exacerbations—switch to roflumilast if FEV1 is <50% and the patient has chronic bronchitis, or azithromycin particularly in former smokers.
Nonpharmacological Therapies for COPD
Initial Nonpharmacological Therapies
Initial nonpharmacological therapies for COPD are stratified by GOLD according to 'ABE' category as follows:
- Group A
- essential—stopping smoking
- based on local availability—recommended vaccinations
- Groups B and E
- essential—stopping smoking and pulmonary rehabilitation
- based on local availability—recommended vaccinations.
- provided with information about COPD
- supported to avoid exposure to risk factors
- educated about the importance of adherence
- instructed and assessed on correct inhaler device use.
Follow-up Nonpharmacological Therapies
- Routine vaccinations
- Self-management advice
- Assessment of risk factor exposure
- Promoting physical activity
- Encouraging improvements to sleep and nutrition
- Considering new interventions for treatable traits.
For information on each therapeutic agent, refer to the individual summaries of product characteristics.
Management of Exacerbations in Primary Care
Steps to take when evaluating an exacerbation include:
- assessing evidence of COPD, comorbidities, and alternative causes
- examining the patient for symptoms and signs
- categorising exacerbation severity using additional investigations
- determining what triggered the episode.
- mild exacerbations: short-acting bronchodilator therapy only
- moderate exacerbations: short-acting bronchodilator therapy plus oral corticosteroids, with or without antibiotics
- severe exacerbations: hospital admission.
- initial treatment with a SABA, with or without a SAMA (one or two puffs of a metered-dose inhaler every 1 hour for two to three doses, followed by one or two puffs every 2–4 hours based on response to treatment)
- for severe exacerbations, systemic corticosteroids (glucocorticoids; a dose equivalent to 40 mg of prednisone per day for 5 days)
- for patients with increased dyspnoea, sputum volume, and sputum purulence, antibiotic treatment (an aminopenicillin with clavulanic acid, macrolide, or tetracycline for a treatment duration of up to 5 days)
- noninvasive mechanical ventilation.
- severe symptoms—worsening resting dyspnoea, high respiratory rate, decreased blood oxygen saturation, confusion, lethargy
- acute respiratory failure
- new signs such as cyanosis or peripheral oedema
- serious comorbidities such as heart failure
- a lack of home support.
|Box 6: Acute Pharmacological Treatment Recommendations for COPD in Other UK Guidelines,|
Managing Exacerbations of COPD
AWMSG=All Wales Medicines Strategy Group; COPD=chronic obstructive pulmonary disease; SABA=short-acting beta2 agonist
For information on adjunct therapies and respiratory support in the management of exacerbations of COPD, COPD and comorbidities, and COPD and COVID-19, refer to the full guideline.
Expert Commentary on the Guidance
Dr Kevin Gruffydd-Jones FRCGP
Warminster Primary Care Centre, Wiltshire
GOLD has been producing evidence-based reports since 2023 on the diagnosis, management, and prevention of COPD. Unlike NICE guidance on COPD, GOLD reports do not look at cost-effectiveness, but are updated annually, which makes them an attractive source of guidance to local guideline makers in the UK.
The 2023 GOLD report emphasises the heterogeneity of COPD, especially with regard to causation. Traditionally thought of as a tobacco smoking-related disease, approximately 30% of cases in developed countries are due to non-smoking-related causes (such as occupation, severe asthma, other pollutants, or alpha-1 antitrypsin deficiency).
A diagnosis of COPD is made based on the presence of characteristic symptoms of cough, dyspnoea, demonstration of fixed airflow limitation—characterised by a post-bronchodilator FEV1/FVC ratio of <0.7—and exclusion of other conditions (such as lung cancer), which can produce similar findings. This is in line with NICE recommendations, although NICE additionally recommends that all patients with suspected COPD receive a chest X-ray.
A major feature of the GOLD report is the recommendation regarding assessment of a patient with COPD after diagnosis and at routine review. The key features of this are:
- assessment of current symptoms and their impact on the patient, measured using the COPD Assessment Test™
- assessment of the risk of future exacerbations and disease progression
- assessment of comorbid conditions (e.g. heart failure, hypertension, or depression).
Patients are then classified by a simple grouping—A, B, E (formerly A, B, C, D in previous iterations of the report)—according to symptom severity and exacerbation history, and this is linked to initial pharmacotherapy. Patients with a low risk of exacerbations and few symptoms (Group A) should be treated with a regular long-acting bronchodilator (mono- or dual therapy), whereas patients with more symptoms and/or a higher risk of exacerbations (Groups B and E) should be treated with dual bronchodilator LAMA/LABA combination therapy. A blood eosinophil level of >300 cells/mcl indicates that patients at high risk of exacerbations should receive triple LABA/LAMA/ICS therapy. Initial routine assessment of a patient with COPD should probably include determination of the blood eosinophil count.
Other features of the 2023 report remain similar to previous reports and to NICE guidance. There is continued emphasis on nonpharmacological management, such as smoking cessation, immunisation, and pulmonary rehabilitation. Oral steroids and increased inhaled bronchodilator therapy remain the cornerstone of treatment of acute exacerbations of COPD in primary care, with oral antibiotics recommended when there is increased mucus purulence and volume.
|Box 6: Useful Resources|
GOLD=Global Initiative for Chronic Obstructive Lung Disease; AWMSG=All Wales Medicines Strategy Group
Keen to learn more?
Read a Guidelines in Practice article by Dr Kevin Gruffydd-Jones on the 2023 GOLD report here.