The Open Respiratory Medicine Journal ISSN: 1874-3064

DOI: 10.2174/0118743064279064231227070344, 2024, 18, e18743064279064 1

REVIEW ARTICLE OPEN ACCESS

Global Initiative for Chronic Obstructive Lung

Disease (GOLD) 2023 Guidelines Reviewed

Munish Sharma1, Sushil Joshi2, Prakash Banjade3, Shekhar A Ghamande1 and Salim Surani4,*
1
Division of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Medical Center, Baylor College of
Medicine, Temple, Texas
2
Department of Medicine, Mantra Hospital and Research Center, Kanchanpur, Nepal. Nepalese Army Institute of
Health Science, Kathmandu, Nepal
3
Department of Medicine, Manipal College of Medical Sciences, Pokhara, Nepal
4
Adjunct Clinical Professor of Medicine, Texas A and M University, Texas, United States

Abstract:
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report is an essential resource for all clinicians
who strive to provide optimal care to patients with chronic obstructive lung disease (COPD). The annual report of
GOLD makes few revisions and updates besides including data from the preceding year. At an interval, GOLD comes
up with a significant modification in its guidelines, which is generally a major overhaul of the pre-existing guidelines.
According to the latest 2023 updates, published in November 2022, there have been significant advancements made
in the field of COPD. These include the development of more precise definitions for COPD and its exacerbations, the
introduction of a new set of parameters to measure exacerbation severity, and updating the COPD assessment tool.
Additionally, revisions have been made to the initial and follow-up treatment guidelines. The report also simplifies the
treatment algorithm and sheds light on new findings that suggest the use of pharmacological triple therapy can
reduce mortality rates. Furthermore, the report includes discussions on inhaler device selection and adherence to
COPD medications. These improvements demonstrate a continued effort to enhance COPD treatment and
management. Although there are some areas that could benefit from more detailed guidance and explanation, such as
the proper utilization of blood eosinophil counts for treatment decisions, and the establishment of treatment protocols
post-hospitalization, the latest modifications to the GOLD recommendations will undoubtedly aid healthcare providers
in addressing any gaps in patient care. We aim to highlight key changes in the GOLD 2023 report and present a
viewpoint about their potential implications in a real-world clinical scenario.
Keywords: Chronic obstructive lung disease, Bronchoscopy, Computed tomography chest, Global initiative for
chronic obstructive lung disease, Inhalers, Preserved ratio impaired spirometry.

© 2024 The Author(s). Published by Bentham Open.

This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public
License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are
credited.
Received: August 24, 2023
Revised: October 10, 2023
*Address correspondence to this author at the Adjunct Clinical Professor of Medicine, Texas A and M University, Texas,
Accepted: December 11, 2023
United States; E-mail: [email protected]
Published: January 11, 2024
Cite as: Sharma M, Joshi S, Banjade P, Ghamande S, Surani S. Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2023 Guidelines Reviewed. Open Respir Med J, 2024; 18: e18743064279064.
http://dx.doi.org/10.2174/0118743064279064231227070344
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1. INTRODUCTION (GOLD) recom- mendations undergo updates to ensure

The global burden of COPD is anticipated to rise in the that they are aligned with the latest developments and
following decades due to an aging population and innovations. The important objective of the GOLD is to
continuing exposure to risk factors [1]. Every year, the raise awareness about the impact of COPD and assist in its
Global Initiative for Chronic Obstructive Lung Disease prevention and management across the globe. The GOLD
2 The Open Respiratory Medicine Journal, 2024, Vol. 18 Sharma et al.

report, which was initially released in 2001, offers who do not have Forced Expiratory Volume in the first
scientifically backed guidance on COPD diagnosis, stable second (FEV1)/ Forced Vital Capacity (FVC) < 0.7 post
disease management, handling of exacerbations, and bronchodilation but have abnormal spirometry (FEV1 <
comorbidities [2]. Healthcare professionals following 80% of reference post-bronchodilator) [8]. Almost a
GOLD recommendations may improve COPD outcomes quarter of these patients develop fixed airflow obstruction
and reduce resource utilization [3, 4]. We want to in the succeeding 4-5 years, which could represent an
highlight major changes in the GOLD 2023 guideline, opportunity to reduce disease [9, 10].
which is in its 6th edition now [5]. 3. NEW SCREENING AND CASE-FINDING
2. THE NEW DEFINITION OF COPD: WHY WE GUIDELINE
NEEDED IT? GOLD 2023 expands on screening recommendations.
The presence of risk factors, such as more than 20 pack
GOLD now defines COPD as “a heterogeneous lung
years of smoking, developmental issues with lungs,
condition characterized by chronic respiratory symptoms
recurrent respiratory infections, or Symptoms indicative of
(dyspnea, cough, expectoration, exacerbations) due to
COPD should undergo screening spirometry [11].
abnormalities of the airways (bronchitis, bronchiolitis)
Questionnaires and peak flow meters have been proposed
and/or alveoli (emphysema) that cause persistent, often
as potential adjunctive tools for screening purposes [12].
progressive, airflow obstruction” [5, 6]. The
Data on the use of spirometry for screening and early
“heterogeneity” primarily urges us to expand our
diagnosis in children and young adults at risk of COPD due
viewpoint beyond the notion of COPD being a single
to poor lung development have been mixed.
pathogenetic process related to smoking. Implications of
developmental lung issues during perinatal and early 3.1. Value of Computed Tomography (CT) Chest in
childhood, recurrent infections, poorly controlled COPD
asthmatics, biomass fuel exposure, alpha-1 antitrypsin
deficiency, and COPD of unknown cause stretch the The presence of emphysema in CT chest aids in
“etiotypes” beyond the stereotypical focus on smoking diagnosis when spirometry is not diagnostic, and it can
only (Table 1). These etiotypes may spur further research predict a rapid decline in FEV1 and indicate a higher risk
and result in therapeutic implications. GOLD has also of malignancy [13]. Detection of bronchiectasis in COPD,
embraced the concept of preserved ratio impaired which is reported to be around 30% on CT chest, also
spirometry (PRISm). The new definition is also predicts recurrent exacerbations and higher mortality [6,
comprehensive and includes a younger and increased 14]. Lung cancer screening guidelines with low-dose chest
proportion of female subjects, as shown in Table 1. CT scans increase emphysema detection and
characterization. CT chest also helps in lung volume
Table 1. A simple tabular adaptation of etiotypes of reduction surgery (LVRS) or endobronchial valve planning.
COPD based on GOLD 2023.
However, there is no role for routine CT chest scans in
all patients with COPD.
COPD due to genetic causes such as alpha-1 antitrypsin deficiency and
other genetic variants. 3.2. Alterations in ABCD Assessment Tool: Major
COPD due to abnormalities in development of lung during perinatal Implications
and early childhood. Example: premature birth, low birthweight.
COPD due to smoke exposure (active and passive tobacco use, vape or ABCD tool, included in the GOLD guideline prior to
cannabis use). 2023, combined FEV1 with measures of disease severity
COPD due to biomass. that included episodes of COPD exacerbations,
COPD due to infections in childhood, tuberculosis, etc. hospitalization, and patient functional status [15]. It has
COPD associated with Asthma. laid more emphasis on the “treatable” traits of COPD, such
Unknown cause of COPD. as the burden of symptoms and exacerbation history (Fig.
2.1. FEV1, FVC and PRISm 1).

To measure forced vital capacity (FVC) using GOLD 2023 guideline has now phased out categories C
spirometry, the patient must start by taking a deep breath. and D in the assessment tool and replaced them with a
Afterward, they should exhale forcefully and for as long as single category E. Patients with no exacerbation or only
they can manage. The amount of air exhaled during this one exacerbation not leading to hospital admission fall into
maneuver is the FVC. The Forced Expiratory Volume in category A or B. Patients are categorized as A if their
one second (FEV1) is the volume of air that can be mMRC scale is 0-1 or their COPD assessment tool (CAT)
forcefully exhaled in the first second of a Forced Vital score is less than 10. Patients fall into category B if their
Capacity (FVC) maneuver. This measurement is often mMRC scale is 2 or more or their CAT score is 10 or more
lower in patients with obstructive respiratory diseases like [16]. This has not changed as compared to previous
asthma or emphysema. The FEV1/FVC ratio assesses guidelines. Patients in category A have mild symptoms and
whether the respiratory pattern is obstructive, restrictive, typically should be managed with bronchodilators.
or normal [7]. Patients in category B are more symptomatic and
treatment recommendations include dual long-acting bron-
The term PRISm has been proposed to identify patients
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 3

Fig. (1). Shows a simple recreation of ABE assessment tool and pharmacological options based on 2023 GOLD guidelines.

chodilator therapy (long-acting beta-2 agonist, LABA/ elimination of groups C and D, including the more severe
Long-acting muscarinic antagonist, LAMA). Category E patients. There was a likelihood of misclassification of
includes all patients with a history of two or more patients to group C based on improper perception and
exacerbations or one or more exacerbations leading to reporting of symptoms by the patients [19]. Thus, the
hospitalization. (Fig. 1) [5]. The more severe Category E abolishment of categories C and D and the creation of E
patients should be started on dual bronchodilator therapy have lumped patients with greater symptom burden and
(LABA/LAMA). If the blood eosinophil count is ≥ 300 exacerbation risk under the same umbrella. This
cells/microliter, then the recommendation is to consider a facilitated streamlining the correct use of long-acting
triple therapy combination of LABA/LAMA and Inhaled bronchodilators and inhaled corticosteroids in COPD.
corticosteroid (ICS) (Fig. 1). ICS/LABA combination now does not play any role in
Two landmark studies influenced the management of patients with COPD without asthma. Real-life experiences
GOLD group E patients.In the Informing the Pathway of using these recommendations will inform us about the
COPD treatment (IMPACT) trial, triple inhalers impact of these significant changes, but they also raise
(LABA/LAMA/ICS) decreased moderate to severe COPD important questions.
exacerbations by 25 and 15% annually compared to (a) What would be the recommendation by GOLD for
LABA/LAMA and LABA/ICS, respectively [17]. The study resource-limited countries and communities where
also showed 54 ml (on average) improvement in FEV1 at provision for even essential medicines is still a challenge?
the 12-month endpoint compared to LABA/LAMA and 97 (b) What challenges would be with patents for
ml compared to LABA/ICS. 42% of patients on triple manufacturing triple inhaler therapies for developing
inhalers had a four or more-point decrease in St. George's nations [20]?
Respiratory Questionnaire (SGRQ) compared to 34% each
in patients on LABA/LAMA and LABA/ICS inhalers [17]. (c) How widely will the paradigm shift from using
ICS/LABA to only using LAMA/LABA or triple therapy be
Thus, there was an overall improvement in quality of
accepted?
life with the triple inhaler. The Efficacy and Safety of
Triple Therapy in Obstructive Lung. 3.3. Updates on COPD Exacerbation, its
The disease (ETHOS) trial also tested triple inhalers Management, Discharge and Follow-up
with LABA/LAMA and LABA/ICS. The annual moderate to With the recognition that an exacerbation represents a
severe COPD exacerbation rate was 1.07 in the low-dose major change in the disease trajectory, the 2023 guideline
triple inhaler group compared to 1.42 in LABA/LAMA and has come up with a new definition for the exacerbation of
1.24 in LABA/ICS group [18]. COPD. It is now defined as “an event characterized by
A notable change in the new guidelines is the dyspnea and/or cough and sputum that worsen over < 14
4 The Open Respiratory Medicine Journal, 2024, Vol. 18 Sharma et al.

days. It may be associated with tachypnea or tachycardia” help reduce re-hospitalization and provide a better
[21]. The notion of systemic or local inflammation transition of care.
instigated by an airway infection, pollutants, or other
3.4. Bronchoscopic Interventions in COPD. Exploring
triggers has been implicated in COPD exacerbation. The
New Horizon
emphasis is on the etiology and triggers of COPD
exacerbation similar to the section in the definition of It is well known that hyperinflation is a significant
COPD in a stable patient. Addressing confounding factors feature of COPD. It is established that lung volume
such as pneumonia, pulmonary embolism, congestive reduction surgery (LVRS) improves chest wall and
heart failure, acute coronary syndrome, pleural effusion, diaphragm mechanics by removing hyperinflated lungs in
and pneumothorax set treatment priorities. selected patients with COPD. However, LVRS can be
associated with significant morbidity and mortality [22].
Intervention for COPD exacerbation based on 2022 Endoscopic lung volume reduction (ELVR), encompassing
recommendations of mild, moderate, and severe means like endobronchial valves (EBV), sealants, and
classification has also seen a proposed change in the vapor ablation (VA), has been suggested by this report as
current guidelines. Scoring of different variables threshold a viable alternative to LVRS mainly due to less morbidity
that includes visual analog dyspnea scale, respiratory rate, and mortality [22]. EBV is a device that prevents air entry
heart rate, oxygen saturation, C-reactive protein, partial during inspiration but allows the one-way escape of air
pressure of Oxygen, and partial pressure of carbon dioxide and secretions during expiration, thereby promoting
has been used to stratify the severity (Table 2) [21]. There atelectasis of the hyperinflated part of the lung. Lung
were no major changes in the treatment strategy for sealants such as a mixture of fibrin, polymer, and
COPD exacerbations. This guideline has outlined follow-up thrombin can collapse emphysematous areas. Vapor
recommendations for the first 1-4 weeks and 12-16 weeks ablation is the direct application of steam vapor by a
of hospital discharge in COPD patients with spirometry bronchoscope to induce inflammation and subsequent
(Tables 3 and 4). Overall, the follow-up instructions should atelectasis of a lung segment.

Table 2. A simple adaptation of severity of COPD exacerbation from GOLD 2023 guidelines.

Severity of COPD
Variables Used to Classify
Exacerbation
VAS dyspnea < 5, HR < 95 beats/minute, RR < 24
Mild
/minute, resting SaO2 ≥ 92 on room air or baseline oxygen, CRP < 10 mg/liter
VAS dyspnea ≥5, HR ≥95 beats/minute, RR >
Moderate
24/minute, resting SaO2 < 92%, CRP > 10, PaO2 ≤ 60 and/or PaCO2 >45
PaCO2 > 45 and pH < 7.35. Rest criteria same as
Severe
those in “moderate” class
Note: VAS: Visual analogue dyspnea scale, RR: Respiratory rate, HR: heart rate, SaO2: oxygen saturation, CRP: C-reactive protein, PaO2: partial pressure pf
Oxygen, PaCO2: partial pressure of carbon dioxide.

Table 3. shows comparison of follow-up recommendations between 1-4 weeks and 12-16 weeks in GOLD 2023
report. Only difference has been highlighted in a different color. Adapted from GOLD 2023.

Post Bronchodilator FEV1/FVC < 0.7 in COPD Patients

GOLD 1 FEV1 ≥ 80%
GOLD 2 FEV1 ≥ 50% and < 80%
GOLD 3 FEV1 ≥ 30% and < 50%
GOLD 4 FEV1 <30%

Table 4. A simple adaptation of grades of airflow obstruction in COPD (based on post-bronchodilator FEV1).

1-4 Weeks Follow-up 12-16 Weeks Follow-up

-Evaluation of patient’s ability to cope in current environment
-Evaluation of patient’s ability to cope in current environment
-Review patient’s understanding about his/her COPD treatment regimen
-Review patient’s understanding about his/her COPD treatment regimen
-Reassess inhaler technique
-Reassess inhaler technique
-Review need for long term oxygen therapy
-Review need for long term oxygen therapy
-Reassess the need for pulmonary rehabilitation
-Reassess the need for pulmonary rehabilitation
-document CAT or mMRC score
-Document CAT or mMRC score
-Analyze comorbidities
-Analyze comorbidities
-Obtain Spirometry measurement (FEV1).
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 5

A key concept emphasized is the interlobar fissure patients was multifold. GOLD 2023 has discussed the
integrity, which prevents collateral ventilation while interplay between COPD and COVID-19 [28, 29].
describing ELVR choices. If the fissure integrity is > 90% Per GOLD, it is unclear if COPD predisposes patients
as determined by high-resolution CT chest, EBV, VA, to a higher risk of contracting severe acute respiratory
sealants, or LVRS are options for treatment. If collateral syndrome coronavirus 2 (SARS-CoV-2). Even though the
ventilation is present, EBV is excluded, while VA, sealants, results are mixed, the GOLD report includes evidence
and LVRS can still be valid options in selected patients indicating a higher risk of severe COVID-19 in patients
[23, 24]. Discussion about nitrogen cryospray (liquid with COPD [30]. After adjusting for the confounding
nitrogen application to ablate abnormal epithelium and factors, the data included in the GOLD report suggested
cause mucosal regeneration) and rheoplasty (pulsed that there is an overall higher mortality risk in COVID-19
electricity applied by an endobronchial catheter) are patients with COPD (Odds ratio 1.41, 95% confidence
recognized as potential treatment options for chronic interval 1.37 – 1.65) and intensive care unit admission
bronchitis in this current guideline. Similarly, targeted (Odds ratio 1.25, 95% confidence interval 1.08 – 1.51)
lung denervation to blunt the effect of the [31]. Poor compliance with maintenance therapy in COPD,
parasympathetic nervous system and decrease mucus decreased baseline pulmonary reserve, and difficult access
production has been mentioned for patients with frequent to healthcare resources have been signaled as the
COPD exacerbations [6]. predictors of poor outcomes. The guidelines recommend
We feel that advanced bronchoscopy in COPD can be testing even for mild symptoms, considering other co-
an important additional resource for COPD patients not pathogens during COPD exacerbations, and being alert for
improving on optimal medical treatment and pulmonary relapses in these patients.
rehabilitation. A significant investment in a GOLD 2023 has suggested limiting PFT to urgent or
multidisciplinary team infrastructure with trained essential cases for diagnosis of COPD, especially during
interventional pulmonologists is necessary. high COVID-19 prevalence. Reverse-transcriptase
3.5. Pulmonary Rehabilitation. Can polymerase chain reaction (RT-PCR) has been
recommended whenever possible before performing PFT
Telerehabilitation be an Effective Alternative?
during an outbreak [32]. However, these
Pulmonary rehabilitation consists of exercise training, recommendations don’t apply to the current COVID
education for the specific disease process, and learned incidence and prevalence. Current evidence suggests
interventions as a self-management tool [25]. Barriers to continuing corticosteroids and inhaled bronchodilators
utilizing pulmonary rehabilitation include access, during COVID-19 infection. The United States Centers for
availability, and funding. The GOLD guidelines discuss Disease Control and Prevention Advisory Committee of
current evidence on Telerehabilitation programs in COPD. Immunization Practices (ACIP) recommendations for
In a systematic review published in 2022, ten studies pneumococcal vaccination (pneumococcal conjugate
(n=245) were evaluated. There were positive effects of vaccine [PCV] 20 alone or PCV15 followed by
telerehabilitation on functional exercise capacity, anxiety, pneumococcal polysaccharide 23 vaccine) and yearly
depression, quality of life, and the overall impact of COPD influenza vaccine recommendations would not change in
on a patient's personal life. Interestingly, there was no COPD patients during COVID- 19 pandemic per GOLD
overall impact on dyspnea [26]. A Cochrane review report.
concluded that telerehabilitation was safe and achieved
similar outcomes compared to in-person rehabilitation in 3.7. Limitations of GOLD 2023 Guidelines
patients with chronic respiratory diseases. According to the GOLD 2023 report, triple therapy
However, the limitations include a small number of should only be considered a first line of treatment for
studies with a high degree of heterogeneity [27]. GOLD patients whose blood eosinophil count is ≥300 cells/μL
2023 guideline has determined that there is still a need for and who have experienced two moderate or one severe
definite evidence for telerehabilitation. exacerbation. Recent research suggests that patients with
blood eosinophil counts between 100 and 300 cells/L,
There is a need for telerehabilitation to be
especially those who have been hospitalized and are
standardized in terms of mode of delivery, exercise
already taking medication, may benefit from adding an
prescription, post-COPD exacerbation interventions, and
ICS to their current treatment plan [33]. More study is
optimal duration for the maximal derivation of benefit.
required into the use of lower thresholds for triple therapy
Besides, the technology should be user-friendly and easily
commencement.
accessible.
Patients who experience exacerbations are now
3.6. COPD in the Era of Coronavirus Disease 2019 treated using a follow-up protocol that does not define the
(COVID-19) severity or frequency of the exacerbations. Clarity
Due to the outbreak of COVID-19, routine diagnosis regarding how exacerbation severity should affect
and subsequent management of COPD became a treatment choices is required, given the correlation
challenge. With limited regular in-person office visits, between exacerbation severity and the risk of subsequent
difficulties in performing pulmonary function testing exacerbations and/or mortality.
(PFT), and medication shortages, the plight of COPD Receiving treatment recommendations post-
6 The Open Respiratory Medicine Journal, 2024, Vol. 18 Sharma et al.

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