LETTER TO THE EDITOR Year : 2023  |  Volume : 14  |  Issue : 1  |  Page : 65-66

Managing chronic obstructive pulmonary diseases in 2023 – What is new?

Vidushi Rathi, Nitesh Gupta, Manu Madan, Pranav Ish
Department of Pulmonary and Critical Care Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission27-Dec-2022Date of Decision27-Dec-2022Date of Acceptance27-Dec-2022Date of Web Publication31-Jan-2023

Correspondence Address:
Pranav Ish
Department of Pulmonary and Critical Care Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, Room No. 638, 6th Floor, Superspeciality Block, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_145_22

How to cite this article:
Rathi V, Gupta N, Madan M, Ish P. Managing chronic obstructive pulmonary diseases in 2023 – What is new?. Indian J Med Spec 2023;14:65-6
How to cite this URL:
Rathi V, Gupta N, Madan M, Ish P. Managing chronic obstructive pulmonary diseases in 2023 – What is new?. Indian J Med Spec [serial online] 2023 [cited 2023 Feb 15];14:65-6. Available from: http://www.ijms.in/text.asp?2023/14/1/65/368625

Dear Editor,

The updated guidelines[1] by Global obstructive lung disease (GOLD) 2023 for the management of chronic obstructive pulmonary diseases (COPDs) has been released. It is an attempt to provide updated recommendations over previous guidelines[2],[3] for the diagnosis and treatment of COPD based on newer evidence and hence over 380 new references have been added. However, the updates seemed regressive and unfortunately confusing.

The definition of COPD has been modified and the words "preventable and treatable have been removed."[1] The focus is on "persistent and often progressive airflow obstruction." This is a regressive step as the nihilistic attitude toward COPD which was being battled for the past 20 years by GOLD guidelines seems to have been reignited. The sole focus being on obstruction in spirometry, emphysema (termed as pre-COPD), and preserved ratio impaired spirometry are terminologies of unclear significance in terms of risk of developing into COPD. The term early COPD has been clearly stated to be used for biologically early disease, rather than mild cases. Another term young COPD has been proposed for ages 20–50 years old. Certain etiotypes have been proposed including – COPD-G (genetic), COPD-D (development), COPD-C (cigarette), COPD-P (pollution), COPD-I (infection), COPD-A (asthma), and COPD-U (unknown).[4] This adds to the armamentarium of existing taxonomy including nonsmoker COPD, post tuberculosis COPD (TOPD), asthma-COPD overlap (ACO), and ACO syndrome. The significance of this classification on the diagnosis and treatment of COPD needs more studies.

COPD classification to determine treatment has shifted from A,B,C and D groups to A,B and E groups. The aim here is to clarify that Group C patients (which have less symptoms, but do have exacerbations) are practically a very small group. In fact, most of the patients who present to the outpatient department or even to emergencies are those patients who belong to Group B and erstwhile Group D. The advantage of this new group system is that eventually the patients are started with bronchodilators, put on dual bronchodilators if they have severe symptoms, and can be added with an inhaled corticosteroid making a triple therapy if they have recurrent eosinophilic exacerbations. As there are now only 3 groups in COPD- A, B and E; the future guidelines may see a stepwise treatment algorithm for COPD similar to the stepwise approach used in bronchial asthma.[5]

The role of computed tomography (CT) chest has been clearly defined screening for lung cancer, nodules, emphysema, pulmonary artery hypertension, bone density, assessment for lung volume reduction surgery or interventions, and even for assessing small airway involvement.[6] The guidelines conclude that such wealth of information may be of prognostic significance and thus role is increasing. This statement can lead to potential exploitation of CT chest in all COPD patients, like in COVID-19.[7]

The mortality benefit of triple inhalational therapy,[8] rehabilitation, smoking cessation, oxygen, noninvasive ventilation, and lung volume reduction surgery has been tabulated in the guidelines along with the evidence for the same. This is a welcome step as these are the few therapies which can alter the course and survival of the patient.

To conclude, guidelines keep evolving with emerging evidence. However, it is always necessary to understand the clinical implications of the same to improve patient outcomes.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Global Strategy for Prevention, Diagnosis and Management of COPD; 2023. Available from: https://goldcopd.org/2023-gold-report-2/. [Last accessed on 2022 Nov 16].  
    2.Gupta N, Malhotra N, Ish P. GOLD 2021 guidelines for COPD – What's new and why. Adv Respir Med 2021;89:344-6.  
    3.Gupta N, Agrawal S, Chakrabarti S, Ish P. COPD 2020 guidelines – What is new and why? Adv Respir Med 2020;88:38-40.  
    4.Stolz D, Mkorombindo T, Schumann DM, Agusti A, Ash SY, Bafadhel M, et al. Towards the elimination of chronic obstructive pulmonary disease: A Lancet Commission. Lancet 2022;400:921-72.  
    5.Ish P, Malhotra N, Gupta N. GINA 2020: What's new and why? J Asthma 2021;58:1273-7.  
    6.Ezponda A, Casanova C, Divo M, Marín-Oto M, Cabrera C, Marín JM, et al. Chest CT-assessed comorbidities and all-cause mortality risk in COPD patients in the BODE cohort. Respirology 2022;27:286-93.  
    7.Sakthivel P, Ish P. Monitoring organising pneumonia pattern in CT among mild COVID-19: Unclear clinical utility. Adv Respir Med 2022. [Doi: 10.5603/ARM.a2022.0024], PMID: 35199846.  
    8.Martinez FJ, Rabe KF, Ferguson GT, Wedzicha JA, Singh D, Wang C, et al. Reduced All-Cause mortality in the ETHOS trial of budesonide/Glycopyrrolate/Formoterol for chronic obstructive pulmonary disease. A randomized, double-blind, multicenter, parallel-group study. Am J Respir Crit Care Med 2021;203:553-64.