Updated COPD Diagnosis and Treatment

The Global Initiative for Chronic Obstructive Lung Disease (GOLD), an international committee of medical experts, updates its recommendations on the diagnosis and management of chronic obstructive pulmonary disease (COPD) every few years.

The 2022 guideline included a few new updates, including guidance for managing COVID-19 for people who have COPD. Previously, in 2017, the committee made significant changes in how doctors are meant to approach the disease, with a focus shifted to the patient, tailoring treatments to the individual rather than to the stage of ​the disease.

Changes in Definition

Among the key changes in the 2017 update is the definition of COPD itself. In the past, the disease was largely defined by its processes, from the mechanisms of inflammation to the manner in which the disease progressed.

The GOLD committee began to define COPD as a "common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation... usually caused by significant exposure to noxious particles or gases."

The key feature of this change is that it acknowledges that people with no clinical evidence of airway obstruction can have symptoms of the disease, sometimes severe.

So, rather than weighing lab results against symptoms, doctors now focus on the cause, effect, and patient experience to direct the course of treatment.

Changes in Understanding of Disease Development

Our understanding of the development of the disease is improving too. While we largely associate COPD with smoking, the simple fact is that not all smokers get COPD and not all people with COPD are smokers.

In addition to exposure to cigarettes, the GOLD committee recognizes other possible factors linked to the disease, including:

• Poor lung growth during gestation and childhood
• Exposure to noxious chemicals in occupational settings
• Different types of air pollution
• Poor socioeconomic status
• Poorly ventilated dwellings
• Exposure to burning fuels (including wood fires and cooking fuel)
• Other lung disorders (such as chronic bronchitis or infections)
• An abnormal inflammatory response, perhaps congenital or the result of progressive or prior lung injury

These factors mean that screening should include people who have symptoms of COPD, even if they aren't smokers. However, smoking cessation is a strong recommendation for people who have COPD because smoking can worsen the disease—and stopping may help prevent progression.

Changes in Treatment Practices

In the past, treatment plans were determined by a test known as the post-bronchodilator FEV1. Based on the results, the person's disease would be graded as either A (mild), B (moderate), C (severe), or D (very severe). Treatment would then be prescribed based on the grading.

In their 2012 update, the GOLD committee revised the guidelines so that the ABCD grading was determined by both a review of lab results, including the FEV1, and the individual's history of COPD exacerbations.

However, symptoms of COPD don't always match the grade. On the one hand, a person with no evidence of airway obstruction can have severe COPD symptoms. On the other, a person with evidence of moderate obstruction may have few symptoms and manage just fine.

Because of this, the new guidelines recommend that:

• The diagnosis of COPD should be based on spirometry, showing an FEV1 to forced vital capacity (FVC) ratio of <0.7.
• Initial pharmaceutical treatment of COPD should be guided by the severity and number of symptoms. The severity is evaluated by CAT or mMRC, which are subjective self-reported symptom scales.
• After treatment is initiated, follow-up assessment should take into consideration the symptoms of breathlessness and activity limitation, the frequency of exacerbations, and the blood eosinophil count.

With the COPD Assessment Test (CAT), the individual is asked to rate the severity of symptoms or impairment on a scale of zero to five. The test aims to establish the severity of symptoms, as well as how "bad" or "good" a person perceives their illness to be.

The modified Medical Research Council (mMRC) dyspnea scale is a 5-point score for self-assessment of shortness of breath.

Treatment includes include medication, exercise, diet, and smoking cessation. Additionally, lung cancer screening is recommended for people who have COPD, as this has been recognized as a potential risk factor.

COVID-19

Since COPD is affected by COVID-19 infection, this relationship has been addressed in the updated guidelines.

Specifically, the guideline states that:

• The management of COPD should not change due to COVID-19
• People who have COPD should have the same management for COVID-19 infection as people who do not have COPD

However, the guideline acknowledges that people who have COPD are at risk of severe infection and mortality due to COVID-19, and recommendations include public health measures to avoid the infection, such as masks, vaccination, and social distancing, as necessary.