Dr Kevin Gruffydd-Jones Explores the Latest Recommendations from GOLD on the Diagnosis and Management of Chronic Obstructive Pulmonary Disease
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Chronic obstructive pulmonary disease (COPD) has an estimated global prevalence of one in 10 adults, and it is one of the three most common causes of death worldwide—in 2012, the condition accounted for more than 3 million deaths.1 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has been producing evidence-based reports since 2001 that provide comprehensive advice on best practice for the diagnosis, management, and prevention of COPD.1 Unlike NICE guidelines, the GOLD report does not examine cost-effectiveness. The scientific committee is largely secondary-care based, but the report is updated annually (in contrast, the NICE COPD guideline was last updated in 20192). As a result, many of the new recommendations are implemented in UK practice while NICE waits to catch up.
This article will examine the changes most relevant to UK primary care in the 2023 GOLD report.
Definition and Diagnosis
The 2023 GOLD report redefines COPD as ‘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.’1
In practice, a diagnosis of COPD is made on the basis of:1
- characteristic symptoms (chronic cough and dyspnoea with or without sputum production), particularly in those with a history of exposure to COPD risk factors
- a postbronchodilator forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.7.
A physical examination and chest X-ray are also warranted; although not diagnostic, these may help to exclude alternative pathologies and comorbidities.1
Traditionally, COPD was considered a disease connected with exposure to tobacco smoke; however, it is estimated that half of all cases of COPD worldwide have other causes.1,3 Even in high-income countries, up to 30% of cases of COPD are thought to be due to risk factors unrelated to smoking,1,3,4 such as those outlined in Table 1.1
Table 1: Risk Factors to Consider in a Patient History1
|Exposure to tobacco smoke||Primary or second-hand exposure, including as a result of use of recreational drugs|
|Indoor pollution||Incomplete combustion from wood burners, gas appliances|
|External pollution||Past or present exposure to vehicle pollution or industrial pollution|
|Occupation||Exposure to vapours (e.g. pesticides), dusts, asbestos|
|Poor early life lung growth||Low birth weight/prematurity, parental smoking (especially in utero), recurrent early life infections|
|Asthma||Past or current wheezing, family or past history of atopy|
History taking should involve looking for any ‘red flags’, such as weight loss or haemoptysis, that may suggest an alternative diagnosis of lung cancer or tuberculosis (TB).1,5,6 The presence of recurrent purulent sputum should raise suspicion of bronchiectasis or TB (in patients at high risk).1 Symptoms of significant comorbidities—such as ischaemic heart disease, gastro-oesophageal reflux, or rhinitis—should be elicited.1,7
Physical examination is an important element of standard care, but is unlikely to be diagnostic of COPD, as physical signs are unusual until lung function is significantly impaired.1 Some signs (such as cyanosis and lung hyperinflation) are suggestive of, but not specific to, COPD.1 Examination should be carried out to check the health of the respiratory and cardiovascular systems, and a general examination should be conducted to look for signs of anaemia, finger clubbing, and weight loss, which may suggest an alternative diagnosis.1,8,9
Postbronchodilator spirometry is required to establish a diagnosis of COPD.1,2 Although the GOLD report recommends the use of forced spirometry,1 accurate readings may not be possible in some patients—for example, patients who are frail or elderly—and quality-assured, relaxed readings are generally accepted as a viable alternative. For further information on how to conduct quality-assured spirometry (incorporating changes necessitated by the COVID-19 pandemic), see guidelines from the Association for Respiratory Technology and Physiology10 and the Primary Care Respiratory Society.11
All patients should have a chest X-ray to help exclude an alternative lung pathology, and a full blood count to exclude anaemia and check their eosinophil count (which may guide future treatment choices; see the section The Role of Blood Eosinophils).1
Sputum analysis may be warranted if there is a suspicion of TB or bronchiectasis,1 and an electrocardiogram/beta-natriuretic peptide analysis should be arranged if there is suspicion of cardiovascular disease.12,13
Management of Stable Disease
The key aims of the management of ‘stable’ COPD are to:1
- reduce symptoms, including improving exercise tolerance and health status
- reduce future risks of exacerbations, disease progression, and mortality.
In 2011, the GOLD report14 classified COPD into four categories (ABCD) to guide pharmacotherapy according to the severity of symptoms, as measured using the modified Medical Research Council Dyspnoea Score (mMRC; the original MRC Dyspnoea Score15 plus 1) or the COPD Assessment Test (CAT™)16 in addition to considering exacerbation frequency and whether those exacerbations were moderate or severe. ‘Moderate’ exacerbations are those defined as those not requiring hospital admission, and ‘severe’ exacerbations as those requiring admission in the preceding 12 months.
The 2023 GOLD report simplifies these categories as follows:1
- Group A—mMRC 0–1 or CAT™ <10; 0 or 1 moderate exacerbations in the preceding 12 months
- Group B—mMRC ≥2 or CAT™ ≥10; 0 or 1 moderate exacerbations in the preceding 12 months
- Group E—≥1 severe exacerbation leading to hospitalisation or ≥2 moderate exacerbations in the preceding 12 months, irrespective of symptom score.
Determining the proper management strategy requires routine review in primary care. Table 2 outlines the key elements of this review, which should be carried out at least annually, and subsequent nonpharmacological management.1
Table 2: Elements of Routine Primary Care Review and Nonpharmacological Management1,17
|Factor to Be Reviewed||Comment|
|Symptoms (mMRC or CAT™ Score)||If mMRC ≥2 or CAT™ Score ≥10, refer for pulmonary rehabilitation (see Pharmacological Management)|
|Exacerbation history||Check that a self-management plan has been issued (see Pharmacological Management)|
|Smoking status||Encourage smoking cessation|
|Risk factors, including occupation||Identify risk factors that could be avoided|
|Inhaler technique and adherence||If necessary, optimise technique and encourage adherence|
|Exercise level and pulmonary rehabilitation||If appropriate, refer to secondary care|
|Self-management||Check that an action plan has been discussed; provide or signpost to educational materials|
|Vaccination status||One-off pneumococcal vaccination; annual COVID-19 and influenza vaccines|
|Annual FEV1 measurements||Hand-held spirometry will serve to monitor lung-function deterioration|
|Pulse oximetry||Refer for oxygen assessment if two readings 3 weeks apart are ≤92%|
|BMI||Consider dietary referral if <20 mg/kg2|
|Comorbidities||Treat as per national guidelines|
|Anxiety or depression||Consider use of NICE screening questions[A]|
|Social support||Who is the principal carer? (if appropriate)|
|[A] NICE screening questions for use in chronic disease:17|
|mMRC=modified Medical Research Council Dyspnoea Score; CAT™=COPD Assessment Test; FEV1=forced expiratory volume in 1 second; BMI=body mass index|
There are major changes in the 2023 GOLD report concerning pharmacotherapy.1 Initial pharmacotherapy is based on the ‘ABE’ categorisation, as explained in Table 3.1
Table 3: Initial Pharmacotherapy for COPD (Adapted for the UK from GOLD1)
|Group||Exacerbations in the Preceding 12 Months||Symptom Score||Therapy[A]|
|A||0 or 1 moderate exacerbations||mMRC 0–1, CAT™ <10||Bronchodilator, preferably regular long acting|
|B||0 or 1 moderate exacerbations||mMRC ≥2, CAT™ ≥10||LABA/LAMA combination|
|E||≥2 moderate exacerbations or ≥1 severe exacerbation leading to hospitalisation||Irrespective of symptoms||LABA/LAMA combination. If blood eosinophils ≥300 cells/mcl, consider LABA/LAMA/ICS combination|
|[A] A SABA should be provided for immediate relief of symptoms.|
|COPD=chronic obstructive pulmonary disease; GOLD=Global Initiative for Chronic Obstructive Lung Disease; mMRC=modified Medical Research Council Dyspnoea Score; CAT™=COPD Assessment Test; LABA=long-acting beta2 agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid; SABA=short-acting beta2 agonist|
Unlike the NICE guideline,2 the GOLD report recommends that, when an inhaled corticosteroid (ICS) is indicated, this should be prescribed as a long-acting beta2 agonist (LABA)/long-acting muscarinic antagonist (LAMA)/ICS triple inhaler rather than as part of dual LABA/ICS therapy—this is because LABA/LAMA/ICS triple therapy has demonstrated superior efficacy in reducing exacerbations and lowering mortality compared with dual LABA/ICS therapy.1,18,19The NICE guideline adds that an ICS/LABA should be prescribed for patients with coexisting asthma, where GOLD does not suggest any specific therapy for patients with suspected or diagnosed comorbid asthma, and recommends treating them in line with local asthma guidance.1,2
The Role of Blood Eosinophils
The GOLD report emphasises the use of blood eosinophils in judging whether to initiate an ICS.1 A retrospective analysis of several large randomised controlled trials showed that there was little additional benefit of triple therapy compared with dual bronchodilator therapy if a patient’s blood eosinophil count was less than 100 cells/mcl, but that there was maximal effect if their blood eosinophil count was greater than 300 cells/mcl.20,21 The risk of pneumonia with ICS use is greatest in patients with a blood eosinophil count of less than 100 cells/mcl.1
Historic blood eosinophil levels can be used for this purpose, although it is important to note that these may have been affected if the patient was experiencing an acute exacerbation or taking oral steroids at the time of measurement.1 The results are reproducible, especially if the blood eosinophil count is less than 100 cells/mcl, but measurements may need to be repeated if it has ever been over 300 cells/mcl.
If a patient continues to experience dyspnoea and/or exacerbations, then the following should be checked before stepping up therapy:
- adherence and inhaler technique1
- that the continued symptoms are due to COPD and not a comorbidity (for example, lung cancer)1
- whether nonpharmacological treatment, including avoidable triggers, has been optimised.
Figure 1 shows the GOLD process for add-on therapy, which has been adapted for primary care.1
As with initial therapy, and in line with NICE guidance, ICS-containing therapy should be prescribed for patients with coexisting asthma.1
Figure 1: Add-on Pharmacotherapy1
Management of Acute Exacerbations
An acute exacerbation of COPD (also called an ‘ECOPD’ in the GOLD report) is defined as ‘an event characterized by increased dyspnea and/or cough and sputum that worsens in <14 days which may be accompanied by tachypnea and/or tachycardia.’1 The main trigger for exacerbations is viral infection, but bacterial infection, environmental pollution, and occupational factors can also initiate or amplify exacerbations.1
Recovery from an acute exacerbation can take 4–6 weeks, but 20% of patients still have symptoms after 8 weeks; not all patients will return to a pre-exacerbation functional state.1 The main features of exacerbation management in primary care consist of an assessment followed by appropriate treatment.1
It is important to establish the diagnosis. Symptoms of an acute exacerbation of COPD may also be present in other conditions—for example, pneumonia, pulmonary embolism, and acute heart failure—so history taking and examinations should be directed to exclude these.1
The severity and potential need for admission can be determined using the criteria in Table 4.1
Table 4: GOLD Thresholds for Severity of Acute Exacerbations1
|Severity||Dyspnoea VAS Score||RR (breaths/min)||HR (beats/min)||Resting SaO2||CRP (mg/l)||ABG|
|Mild||<5||<24||<95||≥92%[A] and a change ≤3% if known||<10|
|Moderate (meeting at least three of these criteria)||≥5||≥24||≥95||<92%[A] and/or a change >3% if known||≥10||If obtained, may show hypoxaemia (PaO2 ≤60 mmHg) and/or hypercapnia (PaCO2 >45 mmHg) but no acidosis|
|Severe||≥5||≥24||≥95||<92%[A]||≥10||Shows new onset/worsening hypercapnia and acidosis (PaCO2 >45 mmHg, pH <7.35)|
|[A] Breathing ambient air (or patient’s usual oxygen prescription).|
|GOLD=Global Initiative for Chronic Obstructive Lung Disease; VAS=Visual Analogue Dyspnoea Scale; RR=respiratory rate; HR=heart rate; SaO2=oxygen saturation; CRP=C-reactive protein; ABG=arterial blood gas; PaO2=partial arterial pressure of oxygen; PaCO2=partial arterial pressure of carbon dioxide|
Management in Primary Care
Management of exacerbations in primary care should include pharmacological intervention, assessment of social circumstances, and timely follow up.1
The initial treatment for dyspnoea is one or two puffs of a short-acting bronchodilator given via a large volume spacer every hour for two or three doses, then every 2–4 hours until symptoms improve.1 For most patients, there is no advantage to delivering a bronchodilator via a nebuliser, unless they are unable to manage sufficient inspiratory effort or they are on maintenance nebuliser therapy.1
Oral steroids reduce the duration of the exacerbation, and lessen the risk of relapse.1 A dose of 40 mg prednisolone per day for a maximum of 5 days is recommended (longer courses increase the risk of pneumonia).1
A 5-day course of oral antibiotics is recommended for patients who have increased sputum purulence and one (or both) of the following:1
- increased dyspnoea
- a sputum volume indicative of potential bacterial infection.
The GOLD report recommends oral tetracycline (for example, doxycycline 200 mg immediately, followed by 100 mg once daily)1,2 or a macrolide (for example, clarithromycin 500 mg twice daily) as first-line antibiotics. This is in line with NICE recommendations; however, NICE also recommends amoxicillin 500 mg three times a day first line,22 whereas GOLD recommends an aminopenicillin (practically, in the UK this would be amoxicillin) plus clavulanic acid, a macrolide, or a tetracycline.1
This is a notable omission among the recommendations for acute exacerbations in the report. It is important to ensure that acutely unwell patients have adequate home support, that both the patient and any carers have clear instructions in the event that the patient’s condition deteriorates, and that the patient is followed up.
Patients managed acutely in primary care should be followed up at an early stage according to clinical need. All patients should be fully reviewed within 4 weeks of being treated for a COPD exacerbation.1 A comprehensive review should be carried out as per the routine review (see Table 2), but with special reference to the prevention of further exacerbations.1 All hospitalised patients should have their vitamin D levels checked and supplemented if they are deficient in order to reduce the risk of further exacerbations.1
COVID-19 and COPD
COVID-19 can be an important viral trigger for an acute exacerbation of COPD, and should be considered when there is an acute worsening of cough and/or dyspnoea. Patients with COPD who develop COVID-19 infection report excessive tiredness, diarrhoea, and dyspnoea more often than those without COPD.1
In the presence of COVID-19 restrictions, remote COPD reviews can be undertaken for many patients.1 There is no evidence of increased harm compared with face-to-face review, but in-person review may be more appropriate for patients with:1
- communication difficulties
- need for immediate attention for severe medical symptoms
- treatment needs that require in-person attendance
- changes in symptoms necessitating a differential diagnosis work-up that requires a physical exam and/or testing.
It is important for patients to be encouraged to exercise regularly during any lockdown.1 Home-based pulmonary rehabilitation can be offered, but is likely to be less effective than supervised, face-to-face therapy.1,23 All patients should be vaccinated against COVID-19.1
Barriers to Implementing the Strategy
In general, the GOLD recommendations are in line with NICE guidance.1,2 However, NICE advocates LABA/LAMA/ICS triple therapy second line to LABA/ICS or LABA/LAMA dual therapy,2 whereas GOLD recommends considering first-line triple therapy in patients with high blood eosinophils and a history of two or more moderate exacerbations, or one or more severe exacerbations, in the previous year.1 This lower threshold for using LABA/LAMA/ICS triple therapy may be questioned by local formulary committees, and the recommendation to use blood eosinophils to guide therapy may have additional resource implications. The use of historical blood eosinophil counts may lessen this problem though.
There is evidence from a 2021 clinical audit of COPD and asthma in primary care in Wales that NICE- and GOLD-recommended diagnostic and review measurements are not being recorded routinely.24 This is an indication that there is an urgent need for national and local COPD review templates.
COPD remains a cause of considerable mortality and morbidity worldwide and in the UK, and there is increasing recognition of nontobacco-related causes of the disease.
In line with NICE’s 2019 guideline, GOLD’s updated 2023 strategy emphasises the importance of accurate diagnosis supported by postbronchodilator spirometry and nonpharmacological management. Inhaled bronchodilator therapy remains the cornerstone of pharmacological management, but the GOLD strategy has an increased role for triple LABA/LAMA/ICS therapy in patients with exacerbations, especially in the presence of a high blood eosinophil count.
Management of an acute attack of COPD in primary care involves assessing the severity of the attack and the presence of any confounding acute respiratory or cardiac comorbidities, including the need for hospital admission. Therapy with high-intensity short-acting bronchodilators and oral steroids remains the gold standard of primary care management, with short-course oral antibiotics for patients with a change in sputum colour.
Useful educational materials for patients with COPD can be obtained from Asthma and Lung UK.
|Implementation Actions for ICSs|
written by Dr David Jenner, GP, Cullompton, Devon
The following implementation actions are designed to support ICSs with the challenges involved in implementing new guidance at a system level. Our aim is to help you to consider how to deliver improvements to healthcare within the available resources.
|Implementation Actions for Clinical Pharmacists in General Practice|
Written by Shivangee Maurya, Clinical Services Pharmacist, Soar Beyond Ltd
The following implementation actions are designed to support clinical pharmacists in general practice with implementing guidance at a practice level.
According to the World Health Organization, COPD is the third-leading cause of death worldwide, despite being a preventable and treatable condition.[A] This statistic highlights the importance of clinical pharmacists in general practice playing their part in addressing the burden of COPD. The 2023 revision of the GOLD report includes new and updated recommendations relevant to clinical pharmacists that aim to improve the development and implementation of effective management programmes, as well as provide approaches to the prevention, early identification, and treatment of COPD.[B]
Clinical pharmacists can undertake the following key actions in general practice to ensure implementation of the 2023 GOLD report updates:[C]
The i2i Network has a suite of training and implementation resources—both bespoke and free—for clinical pharmacists in general practice, including e-learning and on-demand training delivered by experts and covering a range of long-term conditions, including COPD. Become a free i2i Network member at www.i2ipharmacists.co.uk/.
[A] World Health Organization website. Chronic obstructive pulmonary disease (COPD). www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd) (accessed 14 March 2023).
COPD=chronic obstructive pulmonary disease; GOLD=Global Initiative for Chronic Obstructive Lung Disease; PRISm=preserved ratio impaired spirometry; LABA=long-acting beta2 agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid