What are the management recommendations for Chronic Obstructive Pulmonary Disease (COPD) according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2025 guidelines?

COPD Management According to GOLD 2025 Guidelines

Assessment and Classification

The GOLD 2025 guidelines require spirometry for clinical diagnosis, confirming airflow limitation with a post-bronchodilator FEV1/FVC ratio <70%, and classify patients into four groups (A-D) based on symptom burden and exacerbation history to guide treatment decisions. 1

• Group A: Low symptoms, low exacerbation risk
• Group B: High symptoms, low exacerbation risk
• Group C: Low symptoms, high exacerbation risk
• Group D: High symptoms, high exacerbation risk 1, 2

Symptom assessment should use validated tools like the CAT (COPD Assessment Test) or mMRC dyspnea scale, while exacerbation risk is defined as ≥2 moderate exacerbations or ≥1 hospitalization in the previous year. 1, 3

Pharmacological Management by GOLD Group

Group A (Low Symptoms, Low Risk)

Start with a short-acting bronchodilator (SABA or SAMA) as needed for intermittent symptoms. 2

• If symptoms persist, escalate to a long-acting bronchodilator (LABA or LAMA) 2
• Evaluate effectiveness and consider switching to alternative class if inadequate response 2

Group B (High Symptoms, Low Risk)

Initiate treatment with a long-acting bronchodilator (LABA or LAMA) as monotherapy. 1, 2

• For persistent breathlessness on monotherapy, escalate to dual bronchodilator therapy (LABA/LAMA combination) 1, 2
• LAMA or LAMA+LABA are preferred pathways 4
• Never use inhaled corticosteroids (ICS) as monotherapy due to increased pneumonia risk 2

Group C (Low Symptoms, High Risk)

LAMA is the first-line treatment. 1

• Alternative: LABA + ICS combination 4
• For further exacerbations on LAMA monotherapy, escalate to LAMA + LABA 4
• Consider roflumilast if FEV1 <50% predicted AND patient has chronic bronchitis phenotype 4, 1

Group D (High Symptoms, High Risk)

LAMA or LAMA+LABA combination is first-line treatment. 1, 2

• For persistent symptoms or further exacerbations, escalate to triple therapy (LAMA + LABA + ICS) 4, 1
• Single inhaler triple therapy is preferred over multiple inhalers 1
• Consider roflumilast if FEV1 <50% predicted with chronic bronchitis 4
• Consider macrolide therapy (in former smokers) for recurrent exacerbations 4

Management of Acute Exacerbations

Short-acting inhaled β2-agonists are the initial bronchodilators for acute exacerbations. 1

Mild Exacerbations (Home Management)

• Increase dose or frequency of bronchodilators, or combine β2-agonists and anticholinergics 4
• Antibiotics if ≥2 of the following: increased breathlessness, increased sputum volume, development of purulent sputum 4, 1
• Oral corticosteroids 30 mg daily for one week in selected cases 4
• Reassess within 48 hours 4

Severe Exacerbations (Hospital Management)

• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time 1
• Antibiotics for exacerbations with increased sputum purulence and volume 1
• Non-invasive ventilation (NIV) should be the first mode of ventilation for acute respiratory failure 1
• Air-driven nebulizers with supplemental oxygen by nasal cannulae 4

Non-Pharmacological Interventions

Essential Interventions

Smoking cessation is the single most important intervention that influences the natural history of COPD. 1, 2

• Pharmacotherapy and nicotine replacement therapy increase long-term quit rates 1

Pulmonary rehabilitation is recommended for all symptomatic patients (Groups B, C, and D), especially those with exercise limitation. 4, 1, 2

• Improves symptoms, quality of life, and physical and emotional participation in everyday activities 1
• Combination of aerobic training with strength training provides optimal outcomes 4

Oxygen Therapy

Long-term oxygen therapy is indicated for patients with:

• PaO2 ≤55 mmHg (7.3 kPa) or SaO2 ≤88% with or without hypercapnia, confirmed twice over 3 weeks 4, 1
• PaO2 between 55-60 mmHg (7.3-8.0 kPa) or SaO2 88% with evidence of pulmonary hypertension, peripheral edema, or polycythemia (hematocrit >55%) 4, 1

Vaccinations

Annual influenza vaccination is recommended for all COPD patients. 4, 1

Pneumococcal vaccinations (PCV13 and PPSV23) are recommended for:

• All patients over 65 years 4, 1
• Younger patients with significant comorbidities including chronic heart or lung disease 4, 1

Advanced Interventions

Surgical and Bronchoscopic Options

For selected patients with advanced emphysema refractory to optimized medical care, consider lung volume reduction (surgical or bronchoscopic with endobronchial one-way valves or lung coils). 4, 1

• Surgical bullectomy may be considered in patients with large bulla 4
• Lung transplantation for very severe COPD in selected patients without relevant contraindications 4

Special Populations

Alpha-1 antitrypsin augmentation therapy is recommended for patients with severe hereditary deficiency and established emphysema. 2

Low-dose long-acting oral or parenteral opioids may be considered for dyspnea in patients with severe disease. 2

Follow-up and Monitoring

Regular follow-up is essential to monitor symptoms, exacerbations, and airflow limitation. 1

• Each visit should include discussion of current therapeutic regimen 1
• Assess inhaler technique regularly 1
• Check dose and frequency of medications, symptom relief, smoking status, FEV1, and VC 4
• Consider environmental impact of inhaler devices when selecting treatment options 1

Critical Safety Considerations

Avoid ICS monotherapy in COPD as it increases pneumonia risk without bronchodilator benefit. 2

• Use ICS only in combination with long-acting bronchodilators in patients with exacerbation history 2
• For high doses of ICS (≥1,000 μg/day), use large-volume spacer or dry-powder system 4
• If long-term oral corticosteroids are necessary, provide osteoporosis protection (calcium, vitamin D, hormone replacement, bisphosphonates) 4