Professor David Halpin describes key changes in the GOLD 2022 report, and highlights important recommendations for COPD management in primary care

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Professor David Halpin

  • new definitions for chronic obstructive pulmonary disease (COPD), and the diagnosis and assessment of people with suspected COPD
  • managing COPD with initial pharmacotherapy, monitoring and patient follow up, and escalating or de-escalating therapy
  • options for nonpharmacological treatment, including advice on tele-rehabilitation.

Implementation actions for STPs and ICSs

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The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has been producing reports that offer recommendations on the management of chronic obstructive pulmonary disease (COPD) since 2001. One of the key strengths of the GOLD report is that, unlike the NICE guideline,1 it is updated annually. Major revisions were published in 2007, 2011, and 2017, and the 2021 report contains a new chapter on COPD and COVID-19. GOLD published its 2022 report in November 2021.2

Evidence-based management of people with COPD is essential to minimise their symptoms, maintain exercise capacity, and reduce the risk of exacerbations.2 The GOLD assessment scheme and management recommendations on initial and follow-up pharmacological and nonpharmacological management are firmly established in clinical practice around the world, including in the UK.2

Although COVID-19 was the leading cause of death in England in 2021, COPD remains a major cause of mortality and morbidity.3 The theme for World COPD Day 2021 was ‘healthy lungs—never more important’. The aim of the awareness event was to highlight that, even during the pandemic, COPD remains a leading cause of death worldwide, and to emphasise the importance of maintaining healthy lungs.4

The pandemic has undoubtedly made the diagnosis and routine management of COPD more difficult, but it has also led to insights that may have long-term benefits for patients with COPD. For example, several studies have shown a major decrease in hospital admissions for exacerbations in patients with COPD during the pandemic—a reduction much greater than that achieved by pharmacotherapy.2 This reduction may be due to a number of factors, including the effects of infection control measures, reductions in the circulation of other viruses, improved air quality, and better adherence to medications.5 Maintaining measures that reduce the spread of viruses will be a challenge, as they are unpopular and some also have unwanted effects, but the GOLD 2022 report includes shielding measures—such as mask wearing, minimising social contact, and frequent hand washing—within the list of interventions that prevent the frequency of COPD exacerbations.2

New definitions for people with COPD

The GOLD 2022 report includes new discussions around the global burden of COPD, including data on the increased risk of COPD associated with exposure to high doses of pesticides and ambient levels of particulate matter, as well as information on sex-based differences in prevalence—which highlights the importance of COPD as a health problem in women as well as in men.2 The report also provides new definitions for early COPD, mild COPD, COPD in young people, and pre-COPD.2 These concepts will be important for efforts to identify COPD earlier, when interventions to prevent disease progression may be more effective.6

Diagnosis and initial assessment

There have been no significant changes in the chapter on diagnosis and initial assessment. A diagnosis of COPD is based on the presence of symptoms and airflow obstruction, which is demonstrated by a postbronchodilator forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio of less than 0.7 on spirometry.2 The goals of assessment are to determine the level of airflow limitation, the impact of the disease on the patient’s health, and the risk of future events, such as exacerbations, hospital admissions, or death. To achieve these goals, the GOLD report recommends that assessment of people with suspected COPD must consider:2

  • the presence and severity of the spirometric abnormality
  • the current nature and magnitude of the patient’s symptoms
  • history of moderate and severe exacerbations, and future risk
  • the presence of comorbidities.

The degree of FEV1 impairment, expressed as a percentage of the predicted value, is used to determine the GOLD stage (1–4), but the level of symptoms as determined by the modified Medical Research Council Breathlessness Score or the COPD Assessment Test, and the risk of exacerbations based on the number of moderate or severe exacerbations in the previous year, are used to determine the patient’s GOLD group (A–D, see Figure 1).2 The 2022 report emphasises that this assessment of symptoms and exacerbation risk is recommended only as a basis for determining initial therapy, and is not designed for reassessing patients during follow up.2

Diagnostic spirometry in primary care has been severely disrupted by the pandemic, but it is slowly being restarted following joint guidance from the British Thoracic Society, the Association for Respiratory Technology and Physiology, and the Primary Care Respiratory Society.7 Spirometry is not considered to be an aerosol-generating procedure; however, performing spirometry often induces a cough. To reduce the risk of COVID-19 transmission, all tests should be performed using a single-use antibacterial/antiviral filter, the spirometer should be cleaned between patients, and the operator should wear personal protective equipment.

 

Figure 1—The refined ABCD assessment tool

Figure 1: The refined ABCD assessment tool2

FEV1 =forced expiratory volume in 1 second; FVC=forced vital capacity; GOLD=Global Initiative for Chronic Obstructive Lung Disease; mMRC=modified British Medical Research Council Breathlessness Score; CAT=COPD Assessment Test

Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. GOLD, 2022. Available at: www.goldcopd.org  Reproduced with permission.

Initial management

Following assessment, initial management should address reducing exposure to risk factors, such as smoking cessation, and general advice on healthy living should be provided and any comorbidities managed.2 Patients should also be offered vaccination, including the tetanus, diphtheria, and pertussis vaccine for adults who were not vaccinated in adolescence, and the zoster (shingles) vaccine for adults aged more than 50 years.2 The GOLD 2022 report also includes a new recommendation on ensuring that patients have been vaccinated against COVID-19.2

There have been no significant changes to the discussion of evidence on the effects of pharmacological and nonpharmacological therapies, or to recommendations on the management of stable COPD.2 However, the GOLD 2022 report does comment on the potential benefit of pharmacotherapy in reducing the rate of FEV1 decline.2 The report also discusses further evidence on the benefits of triple therapy with a long-acting beta2 -agonist (LABA)/long-acting muscarinic antagonist (LAMA)/inhaled corticosteroid (ICS), which is associated with reduced mortality compared with LABA/LAMA therapy in symptomatic patients with a history of frequent and/or severe exacerbations.2 In addition, the report explores the evidence that delivering fixed-dose triple-combination therapy in one inhaler may improve patients’ health status compared with treatment delivery using multiple inhalers.2,8

Initial pharmacotherapy

The recommendations on initial pharmacotherapy for patients in groups A–D are unchanged in the GOLD 2022 report.2 Bronchodilators are the recommended initial treatment for patients in groups A, B, and C (see Figure 2).2 The choice of initial therapy for patients in group D who are symptomatic and at risk of exacerbations depends on the intensity of their symptoms, and may also be influenced by their blood eosinophil count.2

Figure 2—Initial pharmacological treatment

Figure 2: Initial pharmacological treatment2

LAMA=long-acting muscarinic antagonist; LABA=long-acting beta2‑agonist; ICS=inhaled corticosteroid; eos=blood eosinophil count in cells per microlitre; mMRC=modified British Medical Research Council Breathlessness Score; CAT=COPD Assessment Test

Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. GOLD, 2022. Available at: www.goldcopd.org  Reproduced with permission.

Patient monitoring and follow up

Patients should be routinely reassessed to determine whether their treatment is effective in improving symptoms and reducing exacerbations.2 Before adjusting a patient’s therapy, it is important to check their inhaler technique and adherence, and it is essential to consider nonpharmacological interventions such as pulmonary rehabilitation and smoking cessation.2 The algorithm proposed by GOLD requires the clinician to identify the predominant treatable trait (for example, persistent dyspnoea, continuing exacerbations, or both), what therapy the patient is currently receiving and, in some circumstances, blood eosinophil count (see Figure 3).2 The clinician should then use either the left-hand side of the figure if the problem is persisting dyspnoea, or the right-hand side for continuing exacerbations, either in isolation or with persistent dyspnoea.

Figure 3—Follow-up treatment

Figure 3: Recommended pathways for follow-up treatment based on predominant symptoms, current therapy, and blood eosinophil count2

LABA=long-acting beta2‑agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid; eos=blood eosinophil count in cells per microlitre; FEV1 =forced expiratory volume in 1 second

Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. GOLD, 2022. Available at: www.goldcopd.org Reproduced with permission. 

Blood eosinophil count

The report recommends using blood eosinophil count as a circulating biomarker to help guide treatment choices to maximise the benefit and minimise the risk of using ICS therapy. It discusses recent data on the role of blood eosinophil count as a predictor of the benefits of ICS therapy in preventing exacerbations and reducing the risk of pneumonia.2 The relationships between blood eosinophil count and the likelihood of benefit and the risk of harm from ICS treatment are continuous;2,9,10 however, the report points out that the recommended thresholds of less than 100 cells/µl and more than 300 cells/µl should be regarded as estimates, rather than precise cut-off values, that can predict different probabilities of treatment benefit.2  A higher blood eosinophil count in patients with COPD is associated with increased lung eosinophil numbers, and the presence of higher levels of biomarkers of type-2 inflammation in the airways.2 These differences in airway inflammation may explain the differential response to ICS treatment according to blood eosinophil count.2  A lower blood eosinophil count has been associated with increased levels of proteobacteria in the airways—notably Haemophilus —and this may explain the increased risk of bacterial infection and pneumonia in patients with a blood eosinophil count of less than 100 cells/µl.2,11

Nonpharmacological management

No major changes have been made to the recommendations on nonpharmacological therapy, which remains an important component of initial and follow-up management.2 Nonpharmacological approaches, such as smoking cessation and pulmonary rehabilitation, are essential in COPD management and, in my opinion, they often have a greater impact than drug therapy.

Rehabilitation

Patients with a high symptom burden and a risk of exacerbations (those in groups B, C, and D) should be encouraged to take part in a structured pulmonary rehabilitation programme that takes into account the individual’s characteristics and comorbidities.2 The report highlights that patients who are older, female, more deprived, and those who have a comorbidity including diabetes, asthma, or a painful condition, are less likely to be referred for pulmonary rehabilitation, and recommends that this should be addressed.2 For the first time, the report also includes a section on tele-rehabilitation, which recommends that tele-rehabilitation is safe and has similar benefits to those of centre-based pulmonary rehabilitation.2 However, it emphasises that the evidence base is still evolving, and that best practice in delivering tele-rehabilitation and remotely assessing patients has not yet been established.2 Nevertheless, tele-rehabilitation offers a way of delivering rehabilitation during the pandemic.2

Nutritional support

Malnutrition in COPD impairs lung function, and is associated with poor exercise tolerance, worsened quality of life, and increased hospitalisations and mortality.2 The nutritional support section of the report has been updated to reflect recent evidence that multimodality treatment combining rehabilitation with nutritional support and protein supplementation may improve fat-free mass, body mass index, and exercise performance.2

Screening for lung cancer

Lung cancer is frequently seen in patients with COPD, and is a major cause of death.2 The GOLD 2022 report describes a new recommendation from the United States Preventive Services Task Force that patients with COPD aged 50–80 years with a 20 pack-year smoking history (smoking one pack per day for 20 years) who currently smoke, or who have quit smoking within the past 15 years, should have an annual low-dose computed tomography scan (LDCT) for lung cancer screening.12 This does not fit with current guidance in the UK, as the UK National Screening Committee does not recommend screening for lung cancer,13 but this may change. Following several trials—including the UK Lung Screening Trial, which showed a significant 20% reduction in lung cancer mortality with a single LDCT14 —screening is being piloted in 10 areas around England.15

COPD in the context of COVID-19

Evidence and advice surrounding the risk of COVID-19 in people with COPD, the differentiation of an exacerbation of COPD from COVID-19, and the management of COVID-19 in people with COPD has not changed significantly since the 2021 report.2,16,17 The main change in this chapter is a new recommendation on vaccination—evidence suggests that COVID-19 vaccination is highly effective against severe acute respiratory syndrome coronavirus-2 infection requiring hospitalisation, intensive care admission, or an emergency department visit, including in those with chronic respiratory disease.2,18  GOLD advises that patients with COPD should receive COVID-19 vaccination in line with national guidance.2

The GOLD 2022 report is available on the GOLD website (www.goldcopd.org), which has been updated with links to patient information. The British Lung Foundation also provides useful information for patients in the UK (www.blf.org.uk).

Key points

  • COPD remains an important cause of morbidity and mortality during the COVID-19 pandemic
  • A diagnosis of COPD should be confirmed with a postbronchodilator spirometry test showing a FEV1 to  FVC ratio of <0.7
  • Diagnostic spirometry should be performed in accordance with infection control guidance
  • Initial pharmacotherapy should be based on the patient’s GOLD group (A–D), which is determined by:
    • level of symptoms (assessed using either CAT or mMRC)
    • number and severity of exacerbations in the past year
  • At follow up, treatment should be escalated or de-escalated based on:
    • the presence of breathlessness and exercise limitation
    • the continued occurrence of exacerbations
    • blood eosinophil count
  • Nonpharmacological therapies, including smoking cessation and rehabilitation, continue to play a vital role in COPD management
  • People with COPD should be included in lung cancer screening programmes
  • Infection control and public health measures have had a marked impact on the occurrence of COPD exacerbations
  • No changes to the management of COPD are required during the pandemic
  • No changes to the management of COVID-19 are required in people with COPD.

COPD=chronic obstructive pulmonary disease; FEV1 =forced expiratory volume in 1 second; FVC=forced vital capacity; GOLD=Global Initiative for Chronic Obstructive Lung Disease; CAT=COPD Assessment Test; mMRC=modified British Medical Research Council Breathlessness Score

Professor David Halpin

Consultant Physician and Honorary Professor of Respiratory Medicine, University of Exeter Medical School

Member of the GOLD Board of Directors and Science Committee

Conflicts of interest

Member of the GOLD Board of Directors and Science Committee; sponsorship to attend international meetings, and honoraria for lecturing, attending advisory boards and preparing educational materials from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, CSL Behring, GSK, Novartis, Pfizer, Sandoz, Sanofi, and Teva

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and 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.

  • Review the current provision of spirometry and ensure it can be safely restarted as part of diagnosis for COPD
  • Ensure that patients who may have been managed as ‘probable COPD’ but without formal spirometry during the pandemic are prioritised for diagnostic spirometry
  • Update local formularies in line with the GOLD algorithms for pharmacotherapy and identify appropriate inhalers, taking into account their acquisition costs
  • Reactivate pulmonary rehabilitation and smoking cessation services that have been suspended during the COVID-19 pandemic
  • Prioritise  patients with COPD for COVID-19 vaccination, and actively search for patients who have not had their full course of vaccinations and encourage them to do so (including flu and pneumococcal vaccines where indicated).

STP=sustainability and transformation partnership; ICS=integrated care system; COPD=chronic obstructive pulmonary disease; GOLD=Global Initiative for Chronic Obstructive Lung Disease

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Reflection is important for continuous learning and development, and a critical part of the revalidation process for healthcare professionals. Reflect on what you have learned after reading this article with our interactive template.

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References

  1. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE Guideline 115. NICE, 2018 (last updated July 2019). Available at: nice.org.uk/ng115
  2. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. GOLD, 2022. Available at: www.goldcopd.org
  3. Office for National Statistics. Monthly mortality analysis, England and Wales: December 2021. London: ONS, 2021. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/monthlymortalityanalysisenglandandwales/december2021
  4. Global Initiative for Chronic Obstructive Lung Disease. World COPD Day 2021. GOLD, 2021. Available at: goldcopd.org/world-copd-day/.
  5. Halpin D, Vogelmeier C, Agusti A. COVID-19 and COPD: lessons beyond the pandemic. Am J Physiol Lung Cell Mol Physiol 2021; 321 (5): L978–L982.
  6. Martinez F, Agusti A, Celli B et al. Treatment trials in young patients with COPD and pre-COPD patients: time to move forward. Am J Respir Crit Care Med 2022; 205 (3): 275–287. 
  7. British Thoracic Society, Association for Respiratory Technology and Physiology, Primary Care Respiratory Society. Risk minimisation in spirometry re-start.  BTS, ARTP, PCRS, 2021. Available at: www.brit-thoracic.org.uk/covid-19/covid-19-resumption-and-continuation-of-respiratory-services/#restarting-spirometry
  8. Halpin D, Worsley S, Ismaila A et al. INTREPID: single- versus multiple-inhaler triple therapy for COPD in usual clinical practice. ERJ Open Res 2021; 7 (2): 1–11.
  9. Bafadhel M, Peterson S, De Blas M et al. Predictors of exacerbation risk and response to budesonide in patients with chronic obstructive pulmonary disease: a post-hoc analysis of three randomised trials. Lancet Respir Med 2018; 6 (2): 117–126.
  10. Pascoe S, Barnes N, Brusselle G et al. Blood eosinophils and treatment response with triple and dual combination therapy in chronic obstructive pulmonary disease: analysis of the IMPACT trial. Lancet Respir Med 2019; 7 (9): 745–756.
  11. Martinez-Garcia M, Faner R, Oscullo G et al. Inhaled steroids, circulating eosinophils, chronic airway infection, and pneumonia risk in chronic obstructive pulmonary disease: a network analysis. Am J Respir Crit Care Med 2020; 201 (9): 1078–1085.
  12. Krist A, Davidson K, Mangione C et al. Screening for lung cancer: US preventive services task force recommendation statement. JAMA 2021; 325 (10): 962–970.
  13. GOV.UK UK National Screening Committee website. Lung cancer. view-health-screening-recommendations.service.gov.uk/lung-cancer/ (accessed 10 February 2022).
  14. Field J, Vulkan D, Davies M et al. Lung cancer mortality reduction by LDCT screening: UKLS randomised trial results and international meta-analysis. Lancet Reg Health Eur 2021; 10: 100179.
  15. NHS England website. NHS to rollout lung cancer scanning trucks across the country. www.england.nhs.uk/2019/02/lung-trucks/ (accessed 10 February 2022).
  16. Halpin D, Criner G, Papi A et al. Global initiative for the diagnosis, management, and prevention of chronic obstructive lung disease: the 2020 GOLD science committee report on COVID-19 and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2021; 203 (1): 24–36.
  17. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.  GOLD, 2021. Available at: www.goldcopd.org
  18. Thompson M, Stenehjem E, Grannis S et al. Effectiveness of COVID-19 vaccines in ambulatory and inpatient care settings. N Engl J Med 2021; 385 (15): 1355–1371.

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