26 Apr 2023 • Six years after the last update, the 2023 GOLD report includes newer definitions of COPD and COPD exacerbation, emphasizes combined bronchodilator therapy, and minimizes use of inhaled corticosteroids. Key Points :

• GOLD proposes a new, more-inclusive definition of COPD that focuses on respiratory symptoms, anatomic area of abnormality (airways and alveoli) and airflow obstruction as demonstrated by forced vital capacity/forced expiratory volume in 1 second (FVC/FEV1) <0.7.
• A new definition of COPD exacerbation also is included; it focuses on dyspnea or cough and sputum that worsen during ≤14 days, with associated inflammation due to airway infection, pollution, or other insult to the airways. Severity is determined by dyspnea intensity, respiratory rate, heart rate, and oxygen saturation
• Although cigarette smoking continues to be a predominant cause of COPD, more emphasis is placed on exposure to indoor biomass smoke and air pollution in low- and middle-income countries as a risk factor.
• A new recommendation is made for chest computed tomography if patients have persistent exacerbations, symptoms out of proportion to airflow obstruction, or evidence of air trapping/hyperinflation, to reveal alternate diagnoses or target specific therapies.
• Treatments are determined by (1) degree of airflow obstruction, (2) current symptoms, (3) history of moderate and severe exacerbations, and (4) comorbidities.
• Previous treatment categories C and D have been combined into a new category, named E (for exacerbations). GOLD provides new guidance based on blood eosinophil level. Initial therapy for categories A, B, and E is as follows: A: Long-acting β-agonist (LABA) or long-acting muscarinic antagonist (LAMA) B: LABA + LAMA (change from monotherapy) E: LABA + LAMA; if blood eosinophils are ≥300 cells/µL, consider LABA + LAMA + inhaled corticosteroid (ICS). No recommendation is made (at any eosinophil level) for ICS without combined LABA + LAMA.
• For patients with persistent exacerbations despite LABA + LAMA + ICS or for those who have >100 eosinophils/µL, roflumilast (for patients with chronic bronchitis and FEV1 <50% of predicted) or azithromycin (in nonsmokers) can be considered.
• Pulmonary rehabilitation is recommended for patients in treatment groups B and E.
• Recommendations for oxygen therapy, ventilatory support, and lung-volume reduction surgery are unchanged in this update, although endobronchial valve and endoscopic lung-volume reduction surgery now are included.
• Exacerbations should be treated with bronchodilators and prednisone (40 mg daily for 5 days). A 5-to-7–day course of antibiotics is appropriate for patients with increased sputum volume and purulence or for patients on mechanical ventilation.

Source : NEJM Journal Watch Click here to download the Pocket Guide to GOLD 2023 guidelines