2023 GOLD Guidelines for COPD Prevention, Diagnosis & Management Summary

CHAPTER 1: DEFINITION AND OVERVIEW

Definition

Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction.

Causes and Risk Factors

COPD results from gene(G)-environment(E) interactions occurring over the lifetime(T) of the individual (GETomics) that can damage the lungs and/or alter their normal development/aging processes.
The main environmental exposures leading to COPD are tobacco smoking and the inhalation of toxic particles and gases from household and outdoor air pollution, but other environmental and host factors (including abnormal lung development and accelerated lung aging) can also contribute.
The most relevant (albeit rare) genetic risk factor for COPD identified to date are mutations in the SERPINA1 gene that lead to α-1 antitrypsin deficiency. A number of other genetic variants have also been associated with reduced lung function and risk of COPD, but their individual effect size is small.

Diagnostic Criteria

In the appropriate clinical context (see ‘Definition’ & ‘Causes and Risk Factors’ above), the presence of non-fully reversible airflow obstruction (i.e., FEV1/FVC < 0.7 post-bronchodilation) measured by spirometry confirms the diagnosis of COPD.
Some individuals can have respiratory symptoms and/or structural lung lesions (e.g., emphysema) and/or physiological abnormalities (including low FEV1, gas trapping, hyperinflation, reduced lung diffusing capacity and/or rapid FEV1 decline) without airflow obstruction (FEV1/FVC ≥ 0.7 post-bronchodilation). These subjects are labeled ‘Pre-COPD’. The term ‘PRISm’ (Preserved Ratio Impaired Spirometry) has been proposed to identify those with normal ratio but abnormal spirometry. Subjects with Pre-COPD or PRISm are at risk of developing airflow obstruction over time, but not all of them do.

Clinical Presentation

Patients with COPD typically complain of dyspnea, activity limitation and/or cough with or without sputum production and may experience acute respiratory events characterized by increased respiratory symptoms called exacerbations that require specific preventive and therapeutic measures.
Patients with COPD frequently harbor other comorbid diseases that influence their clinical condition and prognosis and require specific treatment as well. These comorbid conditions can mimic and/or aggravate an acute exacerbation.

New Opportunities

COPD is a common, preventable, and treatable disease, but extensive under-diagnosis and misdiagnosis leads to patients receiving no treatment or incorrect treatment. Appropriate and earlier diagnosis of COPD can have a very significant public-health impact.
The realization that environmental factors other than tobacco smoking can contribute to COPD, that it can start early in life and affect young individuals, and that there are precursor conditions (Pre-COPD, PRISm), opens new windows of opportunity for its prevention, early diagnosis, and prompt and appropriate therapeutic intervention.

A diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, a history of recurrent lower respiratory tract infections and/or a history of exposure to risk factors for the disease, but spirometry showing the presence of a post-bronchodilator FEV1/FVC < 0.7 is mandatory to establish the diagnosis of COPD.
The goals of the initial COPD assessment are to determine the severity of airflow obstruction, the impact of disease on the patient’s health status, and the risk of future events (such as exacerbations, hospital admissions, or death), to guide therapy.
Additional clinical assessment, including the measurement of lung volumes, diffusion capacity, exercise testing and/or lung imaging may be considered in COPD patients with persistent symptoms after initial treatment.
Concomitant chronic diseases (multimorbidity) occur frequently in COPD patients, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer. These comorbidities should be actively sought, and treated appropriately when present, because they influence health status, hospitalizations and mortality independently of the severity of airflow obstruction due to COPD.

Global Strategy for Prevention, Diagnosis and Management of COPD 2024 Report