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Overview

This is a Guidelines summary of the Global Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: 2021 report

This summary includes information on the diagnosis, assessment, management of stable COPD, management of exacerbations, and COPD and co-morbidities.

For further recommendations, download the full GOLD strategy for COPD:

Global strategy for diagnosis, management, and prevention of COPD 2021

Pocket guide to COPD diagnosis, management and prevention 2021

View this summary online at guidelines.co.uk/455088.article

Diagnosis

  • COPD should be considered in any patient who has dyspnoea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.

Key indicators for considering a diagnosis of COPD 

  • Consider COPD, and perform spirometry, if any of these indicators are present in an individual over age 40. These indicators are not diagnostic themselves, but the presence of multiple key indicators increases the probability of a diagnosis of COPD. Spirometry is required to establish a diagnosis of COPD:
    • dyspnoea that is:
      • progressive over time 
      • characteristically worse with exercise
      • persistent
    • chronic cough:
      • may be intermittent and may be unproductive
      • recurrent wheeze 
    • chronic sputum production:
      • any pattern of chronic sputum production may indicate COPD
    • recurrent lower respiratory tract infections
    • history of risk factors:
      • host factors (such as genetic factors, congenital/developmental abnormalities, etc) 
      • tobacco smoke (including popular local preparations) 
      • smoke from home cooking and heating fuels
      • occupational dusts, vapours, fumes, gases, and other chemicals
    • family history of COPD and/or childhood factors:
      • for example, low birthweight, childhood respiratory infection, etc.

Assessment

Classification of airflow limitation severity in COPD (based on post-bronchodilator FEV1)

  • In patients with FEV1/FVC < 0.70:
    • GOLD 1—mild: FEV1≥ 80% predicted 
    • GOLD 2—moderate: 50% ≤ FEV1 < 80% predicted
    • GOLD 3—severe: 30% ≤ FEV1 < 50% predicted
    • GOLD 4—very severe: FEV1 < 30% predicted.

Combined COPD assessment

Algorithm 1: The refined ABCD assessment tool

GOLD recommendations for assessing COPD cases and assigning ABCD GOLD groups

© Global Initiative for Chronic Obstructive Lung Disease, 2020. Reproduced with permission. Available at goldcopd.org.

  • In the revised assessment scheme (see Algorithm 1), patients should undergo spirometry to determine the severity of airflow limitation (i.e., spirometric grade). They should also undergo assessment of either dyspnoea using modified Medical Research Council (mMRC), or symptoms using COPD assessment test (CAT™). Finally, their history of moderate and severe exacerbations (including prior hospitalisations) should be recorded
  • The number provides information regarding severity of airflow limitation (spirometric grade 1 to 4) while the letter (groups A to D) provides information regarding symptom burden and risk of exacerbation which can be used to guide therapy
  • Example: Consider two patients—both patients with FEV1 <30% of predicted, CAT™ scores of 18 and one with no exacerbations in the past year and the other with three exacerbations in the past year. Both would have been labelled GOLD D in the prior classification scheme. However, with the new proposed scheme, the subject with three exacerbations in the past year would be labelled GOLD grade 4, group D
  • Refer to Table 1 for a list of differential diagnosis.

Table 1: Differential diagnosis of COPD

DiagnosisSuggestive features

These features tend to be characteristic of the respective diseases, but are not mandatory. For example, a person who has never smoked may develop COPD (especially in the developing world where other risk factors may be more important than cigarette smoking); asthma may develop in adult and even in elderly patients.

© Global Initiative for Chronic Obstructive Lung Disease, 2020. Reproduced with permission. Available at goldcopd.org.

COPD

Onset in mid-life

Symptoms slowly progressive

History of tobacco smoking or exposure to other types of smoke

Asthma

 

 

Onset early in life (often childhood)

Symptoms vary widely from day to day

Symptoms worse at night/early morning

Allergy, rhinitis, and/or eczema also present

Family history of asthma

Obesity coexistence

Congestive heart failure 

Chest X-ray shows dilated heart, pulmonary oedema.

Pulmonary function tests indicate volume restriction, not airflow limitation

Bronchiectasis

Large volumes of purulent sputum

Commonly associated with bacterial infection

Chest X-ray/CT shows bronchial dilation, bronchial wall thickening.

Tuberculosis

 

 

Onset all ages

Chest X-ray shows lung infiltrate

Microbiological confirmation

High local prevalence of tuberculosis

Obliterative bronchiolitis

 

 

Onset at younger age, non-smokers

May have history of rheumatoid arthritis or acute fume exposure

Seen after lung or bone marrow transplantation

CT on expiration shows hypodense areas

Diffuse panbronchiolitis

Predominantly seen in patients of Asian descent

Most patients are male and non-smokers

Almost all have chronic sinusitis

Chest X-ray and high-resolution computed tomography show diffuse small centrilobular nodular opacities and hyperinflation

Management of stable COPD

  • The management strategy of stable COPD should be predominantly based on the assessment of symptoms and future risk 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 pharmacological and non-pharmacological interventions.

A. Pharmacological treatment 

Initial pharmacological management

  • See Algorithm 2 for an overview of initial pharmacological treatment
  • Rescue short-acting bronchodilators should be prescribed to all patients for immediate symptom relief.

Algorithm 2: Initial pharmacological treatment

GOLD recommendations for initial pharmacological therapy based on GOLD group

© Global Initiative for Chronic Obstructive Lung Disease, 2020. Reproduced with permission. Available at goldcopd.org.

  • Following implementation of therapy, patients should be reassessed for attainment of treatment goals and identification of any barriers for successful treatment (see Algorithm 3). Following review of the patient response to treatment initiation, adjustments in pharmacological treatment may be needed.

Algorithm 3: GOLD COPD management cycle

GOLD recommendations for the ongoing management of COPD: review, assess, adjust

© Global Initiative for Chronic Obstructive Lung Disease, 2020. Reproduced with permission. Available at goldcopd.org.

  • Group A:
    • all Group A patients should be offered bronchodilator treatment based on its effect on breathlessness. This can be either a short- or a long-acting bronchodilator 
    • this should be continued if benefit is documented 
  • Group B: 
    • initial therapy should consist of a long-acting bronchodilator. Long-acting inhaled bronchodilators are superior to short-acting bronchodilators taken as needed i.e., pro re nata (prn) and are therefore recommended
    • there is no evidence to recommend one class of long-acting bronchodilators over another for initial relief of symptoms in this group of patients. In the individual patient, the choice should depend on the patient’s perception of symptom relief
    • for patients with severe breathlessness initial therapy with two bronchodilators may be considered
    • Group B patients are likely to have co-morbidities that may add to their symptomatology and impact their prognosis, and these possibilities should be investigated
  • Group C:
    • initial therapy should consist of a single long-acting bronchodilator. In two head-to-head comparisons the tested LAMA was superior to the LABA regarding exacerbation prevention therefore GOLD recommends starting therapy with a LAMA in this group
  • Group D:
    • in general, therapy can be started with a LAMA as it has effects on both breathlessness and exacerbations 
    • for patients with more severe symptoms (order of magnitude of CAT™ ≥20), especially driven by greater dyspnoea and/or exercise limitation, LAMA/LABA may be chosen as initial treatment 
    • in some patients, initial therapy with LABA/ICS may be the first choice; this treatment has the greatest likelihood of reducing exacerbations in patients with blood eosinophil counts ≥300 cells/µl. LABA/ICS may also be first choice in COPD patients with a history of asthma
    • ICS may cause side-effects such as pneumonia, so should be used as initial therapy only after the possible clinical benefits versus risks have been considered.

Follow-up pharmacological management

  • The follow-up pharmacological treatment algorithm (see Algorithm 4) can be applied to any patient who is already taking maintenance treatment(s) irrespective of the GOLD group allocated at treatment initiation. The need to treat primarily dyspnoea/exercise limitation or prevent exacerbations further should be evaluated. If a change in treatment is considered necessary then select the corresponding algorithm for dyspnoea (see Algorithm 4, left column) or exacerbations (see Algorithm 4, right column); the exacerbation algorithm should also be used for patients who require a change in treatment for both dyspnoea and exacerbations. Identify which box corresponds to the patient’s current treatment.

Algorithm 4: Follow-up pharmacological treatment

An algorithm depicting the GOLD recommendations for adjusting or escalating treatment based on dyspnoea and exacerbations

© Global Initiative for Chronic Obstructive Lung Disease, 2020. Reproduced with permission. Available at goldcopd.org.

  • Follow up pharmacological management should be guided by the principles of first review and assess, then adjust if needed:
    • review
      • review symptoms (dyspnea) and exacerbation risk
    • assess
      • assess inhaler technique and adherence, and the role of non-pharmacological approaches (covered later in this chapter)
    • adjust
      • adjust pharmacological treatment, including escalation or de-escalation. Switching inhaler device or molecules within the same class (e.g. using a different long acting bronchodilator) may be considered as appropriate. Any change in treatment requires a subsequent review of the clinical response, including side effects.

Dyspnoea

  • For patients with persistent breathlessness or exercise limitation on long-acting bronchodilator monotherapy, the use of two bronchodilators is recommended:
    • if the addition of a second long acting bronchodilator does not improve symptoms, GOLD suggests the treatment could be stepped down again to monotherapy. Switching inhaler device or molecules can also be considered
  • For patients with persistent breathlessness or exercise limitation on LABA/ICS treatment, LAMA can be added to escalate to triple therapy:
    • alternatively, switching from LABA/ICS to LABA/LAMA should be considered if the original indication for ICS was inappropriate (e.g. an ICS was used to treat symptoms in the absence of a history of exacerbations), or there has been a lack of response to ICS treatment, or if ICS side-effects warrant discontinuation
  • At all stages, dyspnoea due to other causes (not COPD) should be investigated and treated appropriately. Inhaler technique and adherence should be considered as causes of inadequate treatment response.

Exacerbations

  • For patients with persistent exacerbations on long-acting bronchodilator monotherapy, escalation to either LABA/LAMA or LABA/ICS is recommended. LABA/ICS may be preferred for patients with a history or findings suggestive of asthma. Blood eosinophil counts may identify patients with a greater likelihood of a beneficial response to ICS. For patients with one exacerbation per year, a peripheral blood level ≥300 eosinophils/μl identifies patients more likely to respond to LABA/ICS treatment
  • For patients with ≥2 moderate exacerbations per year or at least one severe exacerbation requiring hospitalisation in the prior year, LABA/ICS treatment can be considered at blood eosinophil counts ≥100 cells/μl, as ICS effects are more pronounced in patients with greater exacerbation frequency and/or severity
  • In patients who develop further exacerbations on LABA/LAMA therapy GOLD suggests two alternative pathways. Blood eosinophil counts < 100 cells/μL can be used to predict a low likelihood of a beneficial ICS response:
    • escalation to LABA/LAMA/ICS. A beneficial response after the addition of ICS may be observed at blood eosinophil counts ≥100 cells/μl, with a greater magnitude of response more likely with higher eosinophil counts
    • add roflumilast or azithromycin (see below) if blood eosinophils <100 cells/μl
  • In patients who develop further exacerbations on LABA/ICS therapy, GOLD recommends escalation to triple therapy by adding a LAMA. Alternatively, treatment can be switched to LABA/LAMA if there has been a lack of response to ICS treatment, or if ICS side effects warrant discontinuation
  • In patients treated with LABA/LAMA/ICS who still have exacerbations the following options may be considered:
    • add roflumilast. This may be considered in patients with an FEV1 <50% predicted and chronic bronchitis, particularly if they have experienced at least one hospitalisation for an exacerbation in the previous year
    • add a macrolide. The best available evidence exists for the use of azithromycin, especially in those who are not current smokers. Consideration to the development of resistant organisms should be factored into decision-making.
    • stopping ICS. This can be considered if there are adverse effects (such as pneumonia) or a reported lack of efficacy. However, a blood eosinophil count ≥300 cells/μl identifies patients with the greatest likelihood of experiencing more exacerbations after ICS withdrawal and who subsequently should be followed closely for relapse of exacerbations.

B. Non-pharmacological treatment

  • Non-pharmacological treatment is complementary to pharmacological treatment and should form part of the comprehensive management of COPD
  • After receiving a diagnosis of COPD a patient should be given further information about the condition. Physicians should emphasize the importance of a smoke free environment, prescribe vaccinations, empower adherence to prescribed medication, ensure proper inhaler technique, promote physical activity and refer patients (GOLD B—GOLD D) to pulmonary rehabilitation
  • Some relevant non-pharmacological measures based on the GOLD group AT DIAGNOSIS are summarised in Table 2.

Table 2: Non-pharmacological management of COPD[A]

Patient groupEssentialRecommendedDepending on local guidelines

A

Smoking cessation (can include pharmacological treatment)

Physical activity

Flu vaccination

Pneumococcal vaccination

Pertussis vaccination

B, C and D

Smoking cessation (can include pharmacological treatment)

Pulmonary rehabilitation

Physical activity

Flu vaccination

Pneumococcal vaccination

Pertussis vaccination

[A] Can include pharmacological treatment

© Global Initiative for Chronic Obstructive Lung Disease, 2020. Reproduced with permission. Available at goldcopd.org.

Education, self-management, and pulmonary rehabilitation

  • Education is needed to change patients’ knowledge but there is no evidence that used alone it will change patient behaviour
  • Education self-management with the support of a case manager with or without the use of a written action plan is recommended for the prevention of exacerbation complications such as hospital admissions
  • Rehabilitation is indicated in all patients with relevant symptoms and/or a high risk for exacerbation 
  • Physical activity is a strong predictor of mortality. Patients should be encouraged to increase the level of physical activity although we still don’t know how to best ensure the likelihood of success.

Vaccination

  • Influenza vaccination is recommended for all patients with COPD
  • Pneumococcal vaccinations PCV13 and PPSV23 are recommended for all patients >65 years of age. The PPSV23 is also recommended in younger patients with significant co-morbid conditions including chronic heart or lung disease.

Nutrition

  • Nutritional supplementation should be considered in malnourished patients with COPD.

End of life and palliative care

  • All clinicians managing patients with COPD should be aware of the effectiveness of palliative approaches to symptom control and use these in their practice 
  • End of life care should include discussions with patients and their families about their views on resuscitation, advance directives and place of death preferences.

Treatment of hypoxemia 

  • In patients with severe resting hypoxemia long-term oxygen therapy is indicated 
  • In patients with stable COPD and resting or exercise-induced moderate desaturation, long term oxygen treatment should not be routinely prescribed. However, individual patient factors may be considered when evaluating the patient’s needs for supplemental oxygen
  • Resting oxygenation at sea level does not exclude the development of severe hypoxemia when travelling by air.

Treatment of hypercapnia

  • In patients with severe chronic hypercapnia and a history of hospitalisation for acute respiratory failure, long term noninvasive ventilation may be considered.

Interventional bronchoscopy and surgery

Management of exacerbations

  • An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy
  • As the symptoms are not specific to COPD relevant differential diagnoses should be considered
  • Exacerbations of COPD can be precipitated by several factors. The most common causes are respiratory tract infections 
  • The goal for treatment of COPD exacerbations is to minimise 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 acute exacerbation 
  • Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 
  • Systemic corticosteroids can improve lung function (FEV1), oxygenation and shorten recovery time and hospitalisation duration. Duration of therapy should not be more than 5–7 days
  • Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalisation duration. Duration of therapy should be 5–7 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 hospitalisation duration and improves survival
  • Following an exacerbation, appropriate measures for exacerbation prevention should be initiated.

COPD and co-morbidities

  • COPD often coexists with other diseases (co-morbidities) that may have a significant impact on disease course
  • In general, the presence of co-morbidities should not alter COPD treatment and co-morbidities should be treated per usual standards regardless of the presence of COPD
  • Cardiovascular diseases are common and important co-morbidities in COPD
  • Lung cancer is frequently seen in patients with COPD and is a major cause of death
  • Osteoporosis and depression/anxiety are frequent, important co-morbidities in COPD, are often under diagnosed, and are associated with poor health status and prognosis
  • Gastroesophageal reflux 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 minimise polypharmacy.

COVID-19 and COPD

Key recommendations

  • Patients 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 as there is no evidence that COPD medications should be changed during this COVID-19 pandemic
  • 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 at goldcopd.org.

Risk of infection with SARS-CoV-2

  • On current evidence, patients with COPD do not seem to be at greatly increased risk of infection with SARS-CoV-2, but this may reflect the effect of protective strategies. They are at an increased risk of hospitalisation for COVID-19 and may be at increased risk of developing severe disease and death.

Investigations

  • Patients with COPD presenting with respiratory symptoms, fever or other symptoms suggesting SARS-CoV-2 infection, even if mild, should be tested for possible infection
  • If patients with COPD have been exposed to someone with known COVID-19 infection they should contact their health care provider to define the need for specific testing. Antibody testing may be used to support clinical assessment of patients who present late.

Protective strategies for patients with COPD

  • Patients with COPD should follow basic infection control measures to help prevent SARS-CoV-2 infection including social distancing and washing hands
  • Wearing a tight-fitting N95 mask introduces an additional inspiratory resistance
  • Whenever possible patients should wear masks. In most cases, a looser face covering, or even a face shield may be tolerable and effective
  • If patients with COPD are asked to shield it is important that they are given advice about keeping active and exercising as much as possible whilst shielded. Plans should be made to ensure supplies of food, medications, oxygen, supportive health services and other basic necessities can be maintained.

Differentiating COVID-19 infection from daily symptoms of COPD

  • Cough and breathlessness are found in over 60% of patients with COVID-19 but are usually also accompanied by fever (> 60% of patients) as well as fatigue, confusion, diarrhea, nausea, vomiting, muscle aches and pains, anosmia, dysgeusia and headaches
  • In COVID-19 symptoms may be mild at first, but rapid deterioration in lung function may occur. The prodrome of milder symptoms is especially problematic in patients with underlying COPD who may already have diminished lung reserve
  • A high index of suspicion for COVID-19 needs to be maintained in patients with COPD who present with symptoms of an exacerbations, especially if accompanied by fever, impaired taste or smell or gastrointestinal complaints.

Maintenance pharmacological treatment for COPD during the COVID-19 pandemic

  • There is an increased risk of pneumonia associated with ICS use, raising concerns that immunosuppression with ICS could increase susceptibility to infections in some individuals
  • There are no conclusive data to support alteration of maintenance COPD pharmacological treatment either to reduce the risk of developing COVID-19, or conversely because of concerns that pharmacological treatment may increase the risk of developing COVID-19
  • There is no data on the use of long-acting bronchodilators, LAMA or LABA, roflumilast, macrolides in patients with COPD and clinical outcomes/risk of SARS-CoV-2 infection; thus, unless evidence emerges, these patients should continue these medications required for COPD.

Use of nebulisers

  • There is a risk that patients may exhale contaminated aerosol and droplets produced by coughing when using a nebuliser may be dispersed more widely by the driving gas
  • If possible, pressurised metered-dose inhalers, dry-powder inhalers, and soft mist inhaler should be used for drug delivery instead of nebulisers. The risks of nebulised therapy spreading infection to other people in patient’s homes may can be minimised by avoiding use in the presence of other people, and ensuring that the nebuliser is used near open windows or in areas of increased air circulation
  • Nebulisers may be needed in critically ill patients with COVID-19 receiving ventilatory support. In this case, it is vital to keep the circuit intact and prevent the transmission of the virus. Using a mesh nebuliser in ventilated patients allows adding medication without requiring the circuit to be broken for aerosol drug delivery.

Non-pharmacological treatment for COPD during the COVID-19 pandemic

  • During the COVID-19 pandemic patients with COPD should continue with their non-pharmacological therapy. Patients should receive their annual influenza vaccination
  • Many pulmonary rehabilitation programmes have been suspended during the pandemic to reduce risks of spreading SARS-CoV-2. Whilst case rates are high, centre-based rehabilitation is not appropriate. Patients should be encouraged to keep active at home and can be supported by home-based rehabilitation programmes
  • Technology-based solutions, such as web-based or smartphone applications may be useful to support home rehabilitation during the pandemic.

Review of COPD patients during the COVID-19 pandemic

  • Routine review of patients with COPD can be undertaken remotely.

Treatment of COVID-19 in patients with COPD

  • In the absence of subgroup data, GOLD recommends that COPD patients suffering with COVID-19 should be treated with the same standard of care treatments as other COVID-19 patients. Importantly, there are no known drug interactions between remdesivir and inhaled COPD treatments.

Exacerbations of COPD

  • If COVID-19 infection is suspected, then RT-PCR testing should be conducted. If COVID-19 infection is confirmed, then treatment for COVID-19 infection should be conducted regardless of the presence of COPD.

Systemic corticosteroids

  • Caution has been raised about the widespread use of systemic corticosteroids in patients with COVID-19
  • Systemic steroids should be used in COPD exacerbations according to the usual indications whether or not there is evidence of SARS-CoV-2 infection as there is no evidence that this approach modifies the susceptibility to SARS-CoV-2 infection or worsens outcomes.

Antibiotics

  • Antibiotic treatment for a COPD exacerbation is indicated if patients have at least two of the three cardinal symptoms including increased sputum purulence, or if the patient requires mechanical ventilation
  • Current World Health Organization guidelines recommend broad-spectrum antibiotics in severe COVID-19 patients, guided by local/national guidelines, and in milder COVID-19 infections when there is clinical suspicion of a bacterial infection. In the absence of specific studies, these general considerations would also apply to COPD patients infected with SARS-CoV-2
  • Antibiotics should be used in COPD exacerbations according to the usual indications whether or not there is evidence of SARS-COV-2 infection, particularly as patients with COPD who develop COVID-19 are reported to more frequently develop bacterial or fungal coinfections.

Follow-up of COPD patients who developed COVID-19

  • Patients who developed mild COVID-19 should be followed with the usual protocols used for COPD patients. Patients who developed moderate COVID-19, including hospitalisation and pneumonia but no respiratory failure, should be monitored more frequently and accurately than the usual COPD patients with particular attention to the need for oxygen therapy.

For information on remote COPD patient follow-up during COVID-19 pandemic restrictions, refer to the full guideline.

Footnote

[1] Recommendations by the GOLD Committees for use of any medication are based on the best evidence available from the published literature and not on labeling directives from government regulators. The Committee does not make recommendations for therapies that have not been approved by at least one major regulatory agency.

 

Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease—2021 report. November 2020.

www.goldcopd.org

Published date: 2015.

Last updated: November 2020.