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Chronic obstructive pulmonary disease

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Updated 2024 GOLD guidelines for the diagnosis and management of chronic obstructive pulmonary disease.

Background

Overview

Definition
COPD is a chronic lung disease characterized by non-reversible airflow obstruction and persistent symptoms of dyspnea and productive cough.
1
Pathophysiology
COPD is caused by airway inflammation and remodeling due to environmental exposures, primarily tobacco smoke. Inflammation and oxidative stress in the airway, alveoli, and pulmonary microvasculature causes destruction of lung parenchyma, and loss of elastic recoil in the lung tissue.
2
Epidemiology
In the US, the prevalence of the COPD is estimated at approximately 12,000 persons per 100,000 population.
1
Disease course
These pathologic changes lead to manifestations of irreversible airflow obstruction, as well as a progressive decline in lung function, which can progress to chronic respiratory failure.
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Prognosis and risk of recurrence
The standardized mortality rate of patients with COPD is estimated at 2.7 (95% CI, 2.5-3.0) in men and 4.8 (95% CI, 4.2-5.4) in women, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of chronic obstructive pulmonary disease are prepared by our editorial team based on guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2024), the American Thoracic Society (ATS 2023,2020), the Canadian Thoracic Society (CTS 2023,2012,2011), the American Association for Thoracic Surgery (AATS 2021), the American College of Physicians (ACP ...
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Screening and diagnosis

Indications for screening: as per USPSTF 2016 guidelines, do not obtain screening for COPD in asymptomatic adults.
D
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  • Diagnosis

Classification and risk stratification

Severity assessment: as per GOLD 2024 guidelines, assess 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) in the initial evaluation to guide therapy.
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Diagnostic investigations

History and physical examination: as per GOLD 2024 guidelines, elicit a detailed medical history in patients with known or suspected COPD, including:
Situation
Guidance
Exposures
Smoking
Occupational exposures
Environmental exposures (household/outdoor)
Past medical history
Early life events (prematurity, low birth weight, maternal smoking during pregnancy, passive smoking exposure during infancy)
Asthma, allergy, sinusitis, or nasal polyps
Respiratory infections in childhood
HIV
Tuberculosis
Family history
COPD
Other chronic respiratory diseases
Pattern of symptom development
COPD typically develops in adult life and most patients are conscious of increased breathlessness, more frequent or prolonged "winter colds," and some social restriction for a number of years before seeking medical help
Exacerbations
History of exacerbations or previous hospitalizations for a respiratory disorder
Comorbidities
CVDs
Osteoporosis
Musculoskeletal disorders
Anxiety and depression
Malignancies
Impact on patient's life
Limitation of activity
Missed work and economic impact
Effect on wellbeing
Effect on family routines
Effect on sexual activity
Feelings of depression or anxiety
Social factors
Availability of social and family support
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  • Spirometry

Respiratory support

Long-term oxygen therapy: as per GOLD 2024 guidelines, offer long-term oxygen therapy to improve survival in patients with severe chronic resting arterial hypoxemia (PaO2 ≤ 55 mmHg or < 60 mmHg if there is cor pulmonale or secondary polycythemia).
A
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  • Noninvasive ventilation

Medical management

General principles: as per GOLD 2024 guidelines, aim treatment at reduction of symptoms and future risk of exacerbations. Decide on the management strategy of stable COPD mainly based on the assessment of symptoms and the history of exacerbations.
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  • Short-acting bronchodilators

  • Long-acting bronchodilators

  • ICSs

  • Combination therapy

  • Phosphodiesterase inhibitors

  • Oral corticosteroids

  • Mucolytics

  • Long-term antibiotics

  • Other pharmacological agents

  • Management of acute exacerbations (setting of care)

  • Management of acute exacerbations (short-acting bronchodilators)

  • Management of acute exacerbations (corticosteroids)

  • Management of acute exacerbations (antibiotics)

  • Management of acute exacerbations (PDE4 inhibitors)

  • Management of acute exacerbations (supplemental oxygen)

  • Management of acute exacerbations (noninvasive ventilation, indications)

  • Management of acute exacerbations (noninvasive ventilation, technical considerations)

  • Management of acute exacerbations (invasive ventilation)

  • Management of acute exacerbations (pulmonary rehabilitation)

  • Palliative care (nonpharmacological measures)

  • Palliative care (nutritional support)

  • Palliative care (supplemental oxygen)

  • Palliative care (opioids)

  • Palliative care (neuromuscular electrical stimulation)

  • Palliative care (therapies with no evidence for benefit)

  • Palliative care (end-of-life care)

Nonpharmacologic interventions

Smoking cessation
As per GOLD 2024 guidelines:
Advise smoking cessation in all smoker patients with COPD.
Offer smoking cessation interventions actively in all patients.
A
Insufficient evidence to support the effectiveness and safety of e-cigarettes as a smoking cessation aid.
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  • Avoidance of exposures

  • Physical activity

  • Pulmonary rehabilitation

Therapeutic procedures

Bronchoscopic interventions: as per GOLD 2024 guidelines, offer bronchoscopic interventions, such as endobronchial valves,
A
lung coils,
B
and vapor ablation,
B
to reduce end-expiratory lung volume and improve exercise tolerance, health status, QoL, and lung function at 6-12 months following treatment in selected patients with advanced emphysema.
B

Surgical interventions

Lung volume reduction surgery: as per GOLD 2024 guidelines, offer lung volume reduction surgery to improve survival in patients with severe upper-lobe emphysema and low post-rehabilitation exercise capacity.
A

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  • Surgical bullectomy

  • Lung transplantation

Specific circumstances

Patients with AAT deficiency: as per GOLD 2024 guidelines, consider initiating IV augmentation therapy to slow down the progression of emphysema in patients with α-1 antitrypsin deficiency and COPD (never or ex-smokers with an FEV1 of 35-60% of predicted being the most suitable candidates).
C

Patient education

General counseling
As per GOLD 2024 guidelines:
Provide education in patients with COPD, although education alone has not been shown to be effective to change the patient's behavior.
B
Provide self-management intervention skills to be communicated with a healthcare professional to improve health status and decrease hospitalizations and emergency department visits.
B

Preventative measures

Routine immunizations: as per GOLD 2024 guidelines, offer influenza and SARS-CoV-2 vaccination in patients with COPD.
B
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Follow-up and surveillance

Follow-up: as per GOLD 2024 guidelines, monitor symptoms, exacerbations, and objective measures of airflow limitation during routine follow-ups of patients with COPD to determine when to modify management and to identify any complications and/or comorbidities that May develop.