Guideline Essentials: 2023 GOLD Strategy for Chronic Obstructive Pulmonary Disease

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.

Overview

In 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^[1],[2]

In an expert commentary, Dr Kevin Gruffydd-Jones assesses the significance of the guidance for the primary care management of COPD.

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.

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.

COPD Global Burden

Globally, COPD:

• 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.

For information on the geographic variation in prevalence, economic and social burden, and environmental triggers and risk factors, refer to the full strategy report.

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.

These disturbances of the normal architecture and function of the lung can result in: 

• 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
• Fatigue
• 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 Guidance

See 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^[1],[2]

Symptom Features

The 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.

For information on familial risk, lung ageing, preconditions of COPD, comorbidities and complications, and the taxonomy of COPD aetiotypes, refer to the full strategy report.

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.

See Box 2 for a comparison of diagnostic criteria for COPD from other published UK guidelines.

Differential Diagnoses

Potential differential diagnoses for COPD include:

• asthma
• congestive heart failure
• bronchiectasis
• tuberculosis
• obliterative or diffuse bronchiolitis.

For a comparison of differential diagnoses listed in other guidance, see Box 3.

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.

The 2023 GOLD report proposes a new system, as yet unvalidated by clinical research, that classifies patients with COPD depending on the frequency of exacerbations in the preceding 12 months:

• 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.

Note: CAT™ Score assesses the impact of symptoms on the patient with COPD rather than the severity of symptoms.

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^[3]

For information on screening and case finding, refer to the full strategy report.

Assessment of Suspected COPD

Assessment 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.

History taking should consider: 

• 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.

GOLD recommends adopting a combined approach to the investigation of suspected COPD, as follows:

• 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.

Physical signs of COPD, such as lung hyperinflation and cyanosis, are not always present or diagnostic, so a physical examination may be of limited value. 

Further Tests

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 shows a comparison of first-line and additional tests recommended in other published UK guidelines on COPD.

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.

Accordingly, GOLD recommends providing the following to patients with COPD: 

• support and pharmacotherapy to stop smoking, if applicable
  • note: the safety and efficacy of e-cigarettes are unproven for this indication
• recommended vaccinations for:
  • COVID-19
  • flu
  • pneumonia
  • pertussis, tetanus, and diphtheria in those who did not receive routine childhood immunisations
  • shingles
• pulmonary rehabilitation, comprising
  • exercise training
  • patient education
  • self-management support.

For information on pharmacotherapies for smoking cessation, recommended vaccines, pulmonary rehabilitation, education and self-management, integrated care programmes, supportive, palliative, and end-of-life care, oxygen therapy and ventilatory support, and interventional and surgical therapies for COPD, refer to the full strategy report.

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.

Choice of treatment should be guided by:

• availability
• expense
• effectiveness
• adverse effects.

Pharmacological Therapies for COPD

Pharmacological treatments for COPD act to increase expiratory flow; therapeutic options include: 

• bronchodilators:
  • short-acting beta₂ agonists (SABAs)
  • long-acting beta₂ agonists (LABAs)
• antimuscarinic (anticholinergic) agents:
  • short-acting muscarinic antagonists (SAMAs)
  • long-acting muscarinic antagonists (LAMAs)
• methylxanthines
• anti-inflammatory drugs
• inhaled corticosteroids (ICSs)
• oral glucocorticoids
• phosphodiesterase-4 (PDE4) inhibitors
• antibiotics
• mucolytic agents.

Initial Pharmacotherapy

According 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.

In patients with COPD, an elevated blood eosinophil count is associated with both increased expression of type-2 inflammatory markers in the airways and enhanced effects of ICSs; therefore:

• 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.

The 2023 GOLD recommendations for initial pharmacological treatment of COPD are stratified by 'ABE' category as follows: 

• 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.

In addition, GOLD states that, 'regular and as-needed use of SABA improves FEV₁ and symptoms'; thus:

• 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.

Follow-up Pharmacotherapy

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.

To compare these pharmacological treatment recommendations with those of other guidelines on COPD, see Box 5.

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
  • recommended—exercise
  • based on local availability—recommended vaccinations
• Groups B and E
  • essential—stopping smoking and pulmonary rehabilitation
  • recommended—exercise
  • based on local availability—recommended vaccinations.

In addition to these initial interventions, patients should be:

• 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 the mode of action, effectiveness, and adverse effects of medications for COPD and alternative pharmacological treatments, refer to the full strategy report.

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.

Classification of exacerbation severity depends on the treatment administered, as follows:

• mild exacerbations: short-acting bronchodilator therapy only
• moderate exacerbations: short-acting bronchodilator therapy plus oral corticosteroids, with or without antibiotics
• severe exacerbations: hospital admission.

Pharmacological management of exacerbations of COPD in primary care aims to reduce the impact of the current episode and reduce the likelihood of future episodes, and consists of: 

• 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.

Hospital admission is indicated when the patient has:

• 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.

To compare these treatment recommendations with those of other published UK guidelines on COPD, see Box 6.

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).

The risk of future exacerbations is strongly determined by the history of exacerbations in the preceding 12 months. Prognosis is also linked to the degree of lung function impairment (hence, it is important to carry out spirometry at a routine review). 

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.

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