Last updated November 15, 2022

GOLD 2023 Report for Prevention, Diagnosis and Management of COPD 2023 Report

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, 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 limitation (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-normal 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 labelled ‘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.

CHAPTER 2: DIAGNOSIS AND ASSESSMENT

  • 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 forced spirometry showing the presence of a postbronchodilator 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.

CHAPTER 3: EVIDENCE SUPPORTING PREVENTION AND MAINTENANCE THERAPY

  • Smoking cessation is key. Nicotine replacement and pharmacotherapy reliably increase long-term smoking abstinence rates. Legislative smoking bans and counseling, delivered by healthcare professionals, improve quit rates.
  • There is no evidence to support the effectiveness and safety of e-cigarettes as a smoking cessation aid at present.
  • Pharmacological therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. Data suggest beneficial effects on rates of lung function decline and mortality.
  • Each pharmacological treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and cost, and the patient’s response, preference, and ability to use various drug delivery devices.
  • Inhaler technique needs to be assessed regularly.
  • COVID-19 vaccines are highly effective against SARS-CoV-2 infection and people with COPD should have the COVID-19 vaccination in line with national recommendations.
  • Influenza vaccination decreases the incidence of lower respiratory tract infections.
  • Pneumococcal vaccination decreases the incidence of lower respiratory tract infections.
  • CDC recommends the Tdap vaccination (dTaP/dTPa; pertussis, tetanus and diptheria) for COPD patients who were not vaccinated in adolescence, as well as routine use of shingles vaccine in all COPD patients.
  • Pulmonary rehabilitation with its core components, including exercise training combined with disease-specific education, improves exercise capacity, symptoms, and quality of life across all grades of COPD severity.
  • In patients with severe resting chronic hypoxemia (PaO2 ≤ 55 mmHg or < 60 mmHg if there is cor pulmonale or secondary polycythemia), long-term oxygen therapy improves survival.
  • In patients with stable COPD and resting or exercise-induced moderate desaturation, long-term oxygen treatment should not be prescribed routinely. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen.
  • In patients with severe chronic hypercapnia and a history of hospitalization for acute respiratory failure, long-term non-invasive ventilation may decrease mortality and prevent re-hospitalization.
  • In select patients with advanced emphysema refractory to optimized medical care, surgical or bronchoscopic interventional treatments may be beneficial.
  • Palliative approaches are effective in controlling symptoms in advanced COPD.

CHAPTER 4: MANAGEMENT OF STABLE COPD

  • The management strategy of stable COPD should be predominantly based on the assessment of symptoms and the history of exacerbations.
  • All individuals who smoke should be strongly encouraged and supported to quit.
  • The main treatment goals are reduction of symptoms and future risk of exacerbations.
  • Management strategies include pharmacologic and non-pharmacologic interventions.

CHAPTER 5: MANAGEMENT OF EXACERBATIONS

  • An exacerbation of COPD is defined as an event characterized by dyspnea and/or cough and sputum that worsen over < 14 days. Exacerbations of COPD are often associated with increased local and systemic inflammation caused by airway infection, pollution, or other insults to the lungs.
  • As the symptoms are not specific to COPD relevant differential diagnoses should be considered, particularly pneumonia, congestive heart failure and pulmonary embolism.
  • The goalsfor treatment of COPD exacerbations are to minimize the negative impact of the current exacerbation and to prevent subsequent events.
  • Short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an exacerbation.
  • Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible. In patients with frequent exacerbations and elevated blood eosinophil levels addition of inhaled corticosteroids to the double bronchodilator regimen should be considered.
  • In patients with severe exacerbations, systemic corticosteroids can improve lung function (FEV1), oxygenation and shorten recovery time including hospitalization duration. Duration of therapy should not normally be more than 5 days.
  • Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalization duration. Duration of therapy should be 5 days.
  • Methylxanthines are not recommended due to increased side effect profiles.
  • Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindication because it improves gas exchange, reduces work of breathing and the need for intubation, decreases hospitalization duration and improves survival.
  • Exacerbation recovery time varies, taking up to 4-6 weeks to recover, with some patients failing to return to the pre-exacerbation functional state. Following an exacerbation, appropriate measures for exacerbation prevention should be initiated (see Chapter 3 and Chapter 4).

CHAPTER 6: COPD AND COMORBIDITIES

  • COPD often coexists with other diseases (comorbidities) that may have a significant impact on disease course.
  • In general, the presence of comorbidities should not alter COPD treatment and comorbidities should be treated per usual standards regardless of the presence of COPD.
  • Cardiovascular diseases are common and important comorbidities in COPD.
  • Lung cancer is frequently seen in people with COPD and is a major cause of death.
    • Annual low-dose CT scan (LDCT) is recommended for lung cancer screening in people with COPD due to smoking according to recommendations for the general population
    • Annual LDCT is not recommended for lung cancer screening in people with COPD not due to smoking due to insufficient data to establish benefit over harm
  • Osteoporosis and depression/anxiety are frequent, important comorbidities in COPD, are often under-diagnosed, and are associated with poor health status and prognosis.
  • Gastroesophageal reflux (GERD) is associated with an increased risk of exacerbations and poorer health status.
  • When COPD is part of a multimorbidity care plan, attention should be directed to ensure simplicity of treatment and to minimize polypharmacy.

CHAPTER 7: COVID-19 AND COPD

  • People with COPD presenting with new or worsening respiratory symptoms, fever, and/or any other symptoms that could be COVID-19 related, even if these are mild, should be tested for possible infection with SARS-CoV-2.
  • Patients should keep taking their oral and inhaled respiratory medications for COPD as directed.
  • During periods of high prevalence of COVID-19 in the community, spirometry should be restricted to patients requiring urgent or essential tests for the diagnosis of COPD, and/or to assess lung function status for interventional procedures or surgery.
  • Physical distancing and shielding, or sheltering-in-place, should not lead to social isolation and inactivity. Patients should stay in contact with their friends and families by telecommunication and continue to keep active. They should also ensure they have enough medication.
  • Patients should be encouraged to use reputable resources for medical information regarding COVID-19 and its management.
  • Guidance for remote (phone/virtual/online) COPD patient follow-up and a printable checklist are provided in the full text guidelines.

Recommendation Grading

Overview

Title

Global Strategy for Prevention, Diagnosis and Management of COPD 2023 Report

Authoring Organization

Publication Month/Year

November 14, 2022

Document Type

Guideline

Country of Publication

US

Document Objectives

Evidence-based strategy document for COPD diagnosis, management, and prevention, with citations from the scientific literature.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Diagnosis, Assessment and screening, Treatment, Management, Prevention, Rehabilitation

Diseases/Conditions (MeSH)

D029424 - Pulmonary Disease, Chronic Obstructive

Keywords

chronic obstructive pulmonary disease (COPD), COPD, GOLD