Intensive care medicine

Surgery

Chronic bronchitis

Pulmonary disease

Airway

Obstructive lung disease

Airway obstruction

Internal medicine

COPD

Medicine

Lung disease

Gold standard (test)

Lung

The Lancet Respiratory Medicine

On Nov 14, 2022, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) published their 2023 global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (COPD). Highlights from the 2023 report were presented at the 2022 GOLD International COPD conference. Some of the key changes in the 2023 report include a revised 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.” Additionally, a table has been added with proposed taxonomy for classification of etiotypes of COPD. Nirupama Putcha (Johns Hopkins University School of Medicine, Baltimore, MD, USA) commented “The new definition of COPD appropriately emphasises the heterogeneous nature of the disease. The classification of individuals into “etiotypes” recognises the interplay between susceptibility, exposures, and life course, although the relevance of these to diagnostic and treatment strategies remains unclear.” Chapter 1 of the report also highlights new opportunities to diagnose COPD earlier and treat appropriately. It describes some individuals who present with structural lung lesions and physiological abnormalities without airflow obstruction who are categorised as having the pre-COPD precursor condition. However, Tobias Welte (Hannover Medical School, Hannover, Germany) commented “There are two main phenotypes of COPD (airway inflammation and emphysema), which could be different in clinical symptomatology, but also [in] lung function alterations. Even with a normal FEV1/FVC ratio without airway obstruction COPD can be present when this is confirmed by other findings (ie, chest radiology). In some [instances] this could be the case in advanced disease.” In chapter 2 on diagnosis and assessment, the previous ABCD patient Assessment Tool for initial assessment and initiation of pharmacological management of COPD has been changed to the ABE Assessment Tool. Groups A and B are unchanged, but groups C and D have been merged into a single group E to highlight the clinical relevance of exacerbations. Patients categorised as group A have modified Medical Research Council (mMRC) dyspnoea scale scores of 0–1, a COPD Assessment Test (CAT) score <10, and a history of zero or one moderate exacerbation not leading to hospitalisation. Patients in group B have mMRC scores ≥2, a CAT score ≥10, and a history of zero or one moderate exacerbation not leading to hospitalisation. Patients in group E have a history of ≥2 moderate exacerbations or ≥1 exacerbation leading to hospitalisation, irrespective of their mMRC or CAT scores. Welte commented “The former C category (exacerbations without symptoms) was clinically not relevant; to combine C and D with a focus on exacerbation reflects the clinical situation.” Putcha added “The change better aligns with the presentation of patients in clinical practice.” In chapter 4 on the management of stable COPD, new text has been added that when initiating treatment with long-acting bronchodilators, the preferred choice is a combination of a long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA); a high symptom burden of dyspnoea persists in most patients when using either a LAMA or LABA alone. Additionally, it states that the use of a LABA–inhaled corticosteroid (ICS) combination should not be encouraged in COPD. LABA–ICS has therefore been removed from recommended initial treatments, and LABA–LAMA should be initiated for patients in groups B and E. Putcha commented “The removal of LABA–ICS from recommended initial treatments and [a] more targeted approach for ICS use is more consistent with current evidence and will hopefully lead to more judicious use of ICS in COPD. The algorithm also recommends considering LABA–LAMA–ICS for patients in group E if blood eosinophil counts are ≥300 cells per μL, because of the positive effect of triple treatment on mortality in this patient subgroup. Welte commented “This reflects the fact that corticosteroids mainly are effective when eosinophilic inflammation is present. The threshold used here is conservative; there is a grey area between 100 and 300 eosinophils per μL where ICS might have a place in some patients, however this needs further evaluation.” One final key change to the 2023 report is a new definition of a COPD exacerbation. The previous definition was considered too vague. The new definition is: “an event characterised by increased dyspnoea and/or cough and sputum that worsens in <14 days which may be accompanied by tachypnea and/or tachycardia and is often associated with increased local and systemic inflammation caused by infection, pollution, or other insult to the airways”. Welte commented “This is a precision with regard to the duration of increased symptom before an exacerbation is diagnosed. Only acute deterioration should be called an exacerbation; long-term increase in symptomatology should be called disease progression. Putcha added “The enhanced definition of exacerbations of COPD emphasise the timecourse and offers a systematic framework for assessment and diagnosis of exacerbations, including a recommendation to understand the cause of events.” For the GOLD COPD 2023 report see https://goldcopd.org/2023-gold-report-2/The 2022 GOLD International COPD conference was hosted virtually and live by the Temple Lung Center on Nov 16, 2022, at the Sheraton Philadelphia Downtown hotel (Philadelphia, PA, USA). For the GOLD COPD 2023 report see https://goldcopd.org/2023-gold-report-2/ The 2022 GOLD International COPD conference was hosted virtually and live by the Temple Lung Center on Nov 16, 2022, at the Sheraton Philadelphia Downtown hotel (Philadelphia, PA, USA).

GOLD COPD report: 2023 update