The 2024 GOLD Report, “Global Strategy for Prevention Diagnosis and Management of COPD,” not only includes guideline updates that reflect the latest research on chronic obstructive pulmonary disease (COPD); it also reflects some shifts in thinking about what’s important in COPD treatment, according to Claus Vogelmeier, MD, a lead report author and science committee chair for the Global Initiative for Chronic Obstructive Lung Disease (GOLD), which just released its 6th major update of the report.
Vogelmeier, who heads the Department of Medicine, Pulmonary and Critical Care Medicine at the University Medical Center of the Philipps-University of Marburg, Germany, summarized key changes in the 2024 GOLD COPD guidelines for clinicians at the 2023 GOLD COPD International Conference in Philadelphia on November 14.
These changes include:
- expanded information regarding preserved ratio impaired spirometry (PRISm);
- a new section on hyperinflation;
- clarification about prebronchodilator spirometry;
- a new section on screening for COPD in targeted populations;
- analysis of interstitial lung abnormalities;
- an expanded section on managing inhaled therapy;
- updated vaccination recommendations for patients with COPD; and
- a revised smoking cessation section and new information on smoking cessation pharmacotherapies.
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The 2024 GOLD report reflects a sea change in thinking about smoking cessation.
Table of Contents
Shifts in Thinking About COPD
Although many changes in the 2024 report reflect new research released from January 2022 to July 2023 (148 new references in total), the updated report does more than just incorporate this new research, said Dr Vogelmeier.
The new “consolidated” report continues to refine the definition of COPD and pre-COPD, he noted, saying that report authors “have been discussing intensely how to define COPD,” including whether the definition should be spirometry-based. Other topics actively discussed by the GOLD science committee members who authored the report were when to do post-bronchodilator spirometry, reducing the carbon footprint of inhalers, COPD-asthma overlap, and the continued non-use of biologics for COPD.
Hyperinflation warranted a new section in the 2024 report because committee members saw it as an “underrated” condition, said Dr Vogelmeier. “Right now, we don’t really know how to address hyperinflation, but overall we think it’s a very important topic,” he explained.
The 2024 GOLD report reflects a sea change in thinking about smoking cessation. Vaping, which may in itself lead to long-term respiratory issues, is discouraged as a smoking cessation tool. Instead, the report puts new focus on the use of pharmacotherapies for smoking cessation, said Dr Vogelmeier.
Key Updates for 2024
COPD Diagnosis
A diagnosis of COPD is confirmed with the presence of nonfully reversible airflow obstruction (forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] <0.7 postbronchodilation) measured by spirometry. Symptoms generally include dyspnea, wheezing, chest tightness, fatigue, activity limitation, and/or cough with or without sputum production.
Pre-COPD and PRISm
Patients considered as having pre-COPD or PRISm have a risk for developing airflow obstruction over time. Pre-COPD was recently proposed to include individuals of any age with respiratory symptoms and/or other detectable structural and/or functional abnormalities, without airflow obstruction on forced spirometry. The report authors noted that randomized controlled trials are needed in patients with pre-COPD and young patients with COPD.
PRISm refers to patients with preserved ratio (FEV1/FVC ≥0.7 after bronchodilation) but impaired spirometry (FEV1 <80% of reference after bronchodilation). PRISm is increased among those who currently smoke and formerly smoked and is associated with high and low body mass index, female sex, obesity, and multimorbidity, and it also may lead to a greater risk for cardiopulmonary disease, all-cause and cardiovascular mortality, hospitalization, and airway obstruction.
Up to about one-third of patients with PRISm may transition to having obstructed spirometry, with predictors such as lower baseline FEV1%, increased age, and current smoking status. Overall, the pathogenesis and treatment of PRISm have significant knowledge gaps, according to the committee.
“Not all individuals with pre-COPD or PRISm will eventually develop fixed airflow obstruction over time (and hence COPD) but they should be considered ‘patients’ (because they already suffer symptoms and/or have functional and/or structural abnormalities) and, as such, they deserve care and treatment,” the report authors stated. “The challenge is that there is no evidence on what the best treatment is for these patients yet.”
Hyperinflation
Hyperinflation refers to gas volume in the lungs increasing relative to normal values at the end of spontaneous expiration. It is clinically relevant among patients with COPD and may lead to dyspnea, impaired exercise tolerance, increased hospitalizations, respiratory failure, and increased mortality. Hyperinflation in patients with COPD occurs after the loss of elastic recoil and expiratory flow obstruction.
“The lung can be hyperinflated at rest (static hyperinflation due to the loss of elastic lung recoil as a consequence of emphysema) and/or during exercise (dynamic hyperinflation as a consequence of airflow obstruction) when ventilatory demands are increased and expiratory times are reduced,” the report authors noted.
Lung volumes from body plethysmography or gas dilution are reference measurements for evaluating hyperinflation, although these measures may vary owing to differences in compressible gas volumes or communicating gas volumes. Hyperinflation in patients may be managed with bronchodilators, supplemental oxygen, heliox, pulmonary rehabilitation, pursed lip breathing, or inspiratory muscle training. In some cases of emphysema, where severe hyperinflation may occur, the condition may warrant lung reduction surgery or bronchoscopic lung reduction techniques.
Prebronchodilator Spirometry
According to the 2024 GOLD report, prebronchodilator spirometry may be used to initially assess whether symptomatic patients have airflow obstruction. If this does not show obstruction, postbronchodilator spirometry is not needed unless a very high clinical suspicion of COPD occurs, in which case an FVC volume response may show FEV1/FVC is less than 0.7. Additional tests to evaluate the cause of a patient’s symptoms and follow-up, including repeat spirometry, may be needed.
“If the prebronchodilator values show obstruction the diagnosis of COPD should be confirmed using postbronchodilator measurements,” noted the report authors. “Individuals with a prebronchodilator FEV1/FVC ratio <0.7 that increases to ≥0.7 postbronchodilator have been shown to have an increased risk of future development of COPD, and should be followed closely.”
The report authors noted that interpreting lung function impairment severity relies on having appropriate reference values and that lung reference values change over time and require revising.
COPD Screening
Evaluating symptoms and conducting spirometry in patients having low-dose chest computed tomography for lung cancer screening provides an opportunity to screen individuals for unrecognized COPD symptoms and airflow obstruction, noted the report authors. Male sex, younger age, shorter smoking duration, and being asymptomatic have been linked to detection of airflow obstruction without a previous diagnosis of COPD.
In addition to cigarette smoking, developmental, genetic, and environmental exposures and childhood infections also may increase the risk for COPD, and patients with these risk factors may have chest imaging for assessment of respiratory symptoms. Computed tomography (CT) scans can help identify patients with an increased risk for COPD and for whom spirometry may be considered in the non-lung cancer screening population.
“The use of spirometry in targeted patients undergoing lung cancer screening or when incidental imaging abnormalities are found consistent with parenchymal or airway manifestations of airways disorders is recommended by GOLD,” stated the report authors.
Blood Eosinophil Count-Guided ICS
Blood eosinophil counts are recommended by GOLD to guide the use of inhaled corticosteroids (ICS) in pharmacologic management. Evidence has shown that patients with COPD may have increased average blood eosinophil counts, which may be associated with increased lung eosinophil numbers and levels of markers of type-2 inflammation in the airways. “Blood eosinophil counts can help clinicians estimate the likelihood of a beneficial preventive response to the addition of ICS to regular bronchodilator treatment, and thus can be used as a biomarker in conjunction with clinical assessment when making decisions regarding ICS use,” according to the committee.
Interstitial Lung Abnormalities
Interstitial lung abnormalities (ILA) refer to findings suggestive of parenchymal lung fibrosis or inflammation from CT imaging in individuals who smoke or those who don’t smoke when observed incidentally among patients without known interstitial lung disease. Fibrotic ILA have an increased likelihood of progressing and are associated with poor outcomes, particularly in patients with emphysema. Evidence supports clinical assessment, risk stratification, and follow-up in patients with these findings.
Smoking Cessation and Vaping
The GOLD report advises clinicians to identify patients using tobacco at every visit, to strongly urge these patients to quit, and to assess each patient’s willingness to attempt to quit. Providing a quit plan and practical counseling as well as scheduling follow-up are also key steps to aid patients. Research has shown that a combination of counseling and pharmacotherapy is the most effective smoking cessation therapy for patients with COPD, noted the committee.
The Tobacco Use & Dependence Clinical Practice Guideline Panel found that brief smoking cessation counseling is effective, and that patients who use tobacco should be offered advice at each contact. Effective forms of counseling include practical counseling, social support of family and friends as part of treatment, and social support outside of treatment. Recommended first-line pharmacotherapies for tobacco dependence include varenicline, nortriptyline, bupropion sustained release, nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patch, and the panel recommends that at least 1 of these medications should be prescribed when no contraindications occur.
Vaping is not recommended as a smoking cessation strategy. Electronic cigarettes contain nicotine and other chemicals, and their long-term effects in those who smoke and patients with COPD are largely unknown, noted the report authors. “Based on the available evidence, and the lack of knowledge about the long-term effects of e-cigarettes on respiratory health, it is not possible to recommend this intervention for smoking cessation in patients with COPD,” said the report authors.
In a meta-analysis that compared nicotine replacement therapy, bupropion, nortriptyline, and varenicline with placebo in patients with COPD who smoke, all pharmacotherapies except nortriptyline increased the likelihood for smoking cessation.
Among the available pharmacotherapies for smoking cessation, nicotine replacement therapy in the form of gum, inhaler, nasal spray, transdermal patch, tablet, or lozenge can reliably increase long-term smoking abstinence rates, although it also can cause irritation at the administration site, according to the committee.
Managing Inhaled Therapy
Managing inhaled therapy requires appropriate use of inhaler devices to maximize the benefits and lower the risks. At least 33 inhaled therapies have different bronchodilators and inhaled corticosteroids alone or in combinations, and at least 22 inhaler devices are available. Each device has its own set of instructions, and more than two-thirds of patients make at least 1 error in using a device, noted the authors.
Selecting the right inhaler device depends on drug availability, device characteristics, the patient’s abilities and preferences, and clinicians’ knowledge in caring for the patient. The report authors advised that device types should be minimized and not be switched without clinical justification. “Shared decision-making is the most appropriate strategy for inhalation device choice,” stated the report authors. “Patients’ cognition, dexterity, and strength must be taken into account.”
Vaccinations
GOLD advises that patients with COPD should receive all recommended vaccinations according to relevant guidelines. Influenza vaccination is recommended in patients with stable COPD, and the World Health Organization and US Centers for Disease Control (CDC) recommend SARS-CoV-2 vaccination. The CDC also recommends 1 dose of the 20-valent pneumococcal conjugate vaccine or 1 dose of 15-valent pneumococcal conjugate vaccine followed by the 23-valent pneumococcal polysaccharide vaccine for those with stable COPD. The CDC recommends the respiratory syncytial virus (RSV) vaccine in individuals over 60 years of age and/or with chronic heart or lung disease, as well as the Tdap vaccine for protection against pertussis in patients with COPD who did not receive the vaccination in adolescence and the herpes zoster vaccine for shingles protection in individuals with COPD who are over 50 years of age.
Raising COPD Awareness
Raising awareness of COPD and the importance of early detection and prevention of this diseases is an ongoing priority for GOLD, said report authors. “The GOLD initiative will continue to work with national leaders and other interested health care professionals to bring COPD to the attention of governments, public health officials, health care workers, and the general public to raise awareness of the burden of COPD and to develop programs for early detection, prevention, and approaches to management,” the report authors stated.
Disclosure: Some 2024 GOLD Report authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
