GOLD 2023 Update: Implications for Clinical Practice

Figures & data

Table 1 Summary of Changes in GOLD 2023 Report

Summary of Changes (Including Location in GOLD 2023 Report)

Definition and taxonomy

● New background information on COPD and new strategies for terminology and taxonomy have been incorporated (Chapter 1)

● A new section on chronic bronchitis has been added (Chapter 1, page 13)

● A new definition of COPD has been proposed: COPD is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction (Chapter 1, page 5)

● A new definition of COPD exacerbation has been proposed, and a new set of parameters to assess exacerbation history has been included: an exacerbation of COPD is defined as an event characterized by dyspnea and/or cough and sputum that worsens in <14 days and is often associated with increased local and systemic inflammation caused by airway infection, pollution, or other insult to the lungs (Chapter 1, page 134)

Diagnosis

● Additional information on screening and case finding has been included (Chapter 2, page 36)

● New information on imaging and CT has been included (Chapter 2, page 43)

● The ABCD grouping system has been updated to the ABE model to recognize the clinical relevance of exacerbations, independent of the level of symptoms (Chapter 2, page 40; Chapter 4, page 115)

Exacerbation management ● The topic of management of exacerbations has been expanded to include details of possible alternative causes of symptoms and a new table on diagnosis and assessment (Chapter 5, page 136)

Disease management: pharmacological therapies

● The information and figures outlining initial pharmacological treatment and follow-up pharmacological treatment have been updated; in particular, the positioning of LABA + LAMA and ICS + LABA have been updated (Chapter 4, page 115)

● Further information on therapeutic interventions to reduce COPD mortality has been included (Chapter 3, page 67)

● Issues related to inhaled delivery have been addressed (Chapter 3, page 69)

● Information on the topic of adherence to inhaled COPD medications has been included (Chapter 3, page 71)

● New information on the choice of inhaler device has been added (Chapter 4, page 112)

Disease management: non-pharmacological therapies

● Vaccination recommendations for people with COPD have been updated in line with current guidance from the Centre for Disease Control and Prevention (Chapter 3, page 54)

● A section on tele-rehabilitation has been added (Chapter 3, page 76)

● The section on interventional and surgical therapies for COPD has been expanded (Chapter 3, page 82)

Comorbidities

● The sections on COPD and comorbidities and COVID-19 and COPD have been updated with the latest evidence (Chapter 6, page 154; Chapter 7, page 169)

Notes: Adapted from the GOLD 2023 Report Highlights, Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease report 2023.⁵ Chapters and page numbers from the GOLD 2023 Report are included in the table for ease of reference.

Abbreviations: COPD, chronic obstructive pulmonary disease; CT, computed tomography; ICS, inhaled corticosteroid(s); LABA, long-acting β₂-agonist; LAMA, long-acting muscarinic antagonist.

Table 2 Summary of New Classification of COPD Etiotypes

Classification	Description
Genetically determined COPD (COPD-G)	Alpha-1 antitrypsin deficiency Other genetic variations with smaller effects acting in combination
COPD due to abnormal lung development (COPD-D)	Early life events, including premature birth and low birth weight, among others
Environmental COPD
Cigarette smoking COPD (COPD-C)	Exposure to tobacco smoke, including in utero or via passive smoking Vaping or e-cigarette use Cannabis
Biomass and pollution exposure COPD (COPD-P)	Exposure to household pollution, ambient air pollution, wildfire smoke, occupational hazards
COPD due to infections (COPD-I)	Childhood infections, tuberculosis-associated COPD, WHIV-associated COPD
COPD and asthma (COPD-A)	Particularly childhood asthma
COPD of unknown cause (COPD-U)	-

Notes: Adapted from the Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease report 2023, Celli et al 2022, and Stolz et al 2022.^5,8,9 ©2022 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner.

Abbreviations: COPD, chronic obstructive pulmonary disease; WHIV, women with human immunodeficiency virus.

Figure 1 (A) Consolidated representation of the updated GOLD treatment algorithms, as interpreted by the authors. (B) Initial Pharmacological Treatment and Follow-up Pharmacological Treatment algorithms as presented in the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease report 2023.⁵

Notes: Clinicians should classify treatment-naïve patients as either Groups A, B, or E and prescribe the appropriate treatment as indicated by the algorithm. Patients already receiving treatment should begin at the most appropriate step in the algorithm. (A) adapted from Pharmacological treatment of stable COPD, Figure 4.2, and Figure 4.4, in Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease report 2023.⁵ (B) as presented in Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease report 2023⁵ (Figures 4.2 and 4.4). ©2022 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner. GOLD states that the eosinophil levels in its recommendations are estimates and not precise cutoffs. A holistic evaluation of exacerbation risk should be used to decide when initiating or escalating to ICS-containing therapy. *Single inhaler therapy may be more convenient and effective than multiple inhalers; ^†consider de-escalation of ICS if pneumonia or other considerable side-effects. In case of blood eosinophils ≥300 cells/μL de-escalation is more likely to be associated with the development of exacerbations.

Abbreviations: CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; eos, eosinophils; ICS, inhaled corticosteroid(s); FEV₁, forced expiratory volume in 1 second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; LABA, long-acting β₂-agonist; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council.

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease report; 2023 Availble from: https://goldcopd.org/2023-gold-report-2/. Accessed April 12, 2023.

 Google Scholar

Celli B, Fabbri L, Criner G, et al. Definition and nomenclature of chronic obstructive pulmonary disease: time for its revision. Am J Respir Crit Care Med. 2022;206(11):1317–1325. doi:10.1164/rccm.202204-0671PP

 PubMed Web of Science ®Google Scholar

Stolz D, Mkorombindo T, Schumann DM, et al. Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission. Lancet. 2022;400(10356):921–972. doi:10.1016/S0140-6736(22)01273-9

 PubMed Web of Science ®Google Scholar