Reference: April 2026 | Issue 4 | Vol 12 | Page 34
Late last year, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) released its 2026 Global Strategy for the Diagnosis, Management and Prevention of COPD, unveiling one of the most significant revisions in the history of the clinical guidance. This year’s update introduces important changes across diagnosis, risk stratification, treatment algorithms, exacerbation management, multimorbidity care, and the use of artificial intelligence in practice.
Perhaps the most significant change is the introduction of the disease activity framework. Historically, COPD has been characterised mainly by symptoms and airflow limitation. The 2026 version emphasises that COPD is a dynamic, biologically active disease, with progression driven by underlying inflammatory processes.
GOLD 2026 introduces disease activity as a clinical concept in COPD management – a shift away from relying mainly on spirometric severity and symptom scores to track how actively the disease is progressing. The new guidance focuses on the underlying biological and clinical processes (exacerbations, lung function decline, symptom worsening).
Disease stability is the new treatment goal. This is achieved when these processes are minimised, ie, no exacerbations and stable symptoms.
This new approach encourages a focus on longitudinal disease control. It encourages a pro-active approach to disease stability, achieving low disease activity, preventing exacerbations, and stabilising symptoms and lung function. This marks a significant shift toward goal-oriented management rather than solely reactive treatment. This change matters clinically.
Previously, patients with only one moderate exacerbation might not have qualified for intensified therapy. GOLD 2026 instead endorses earlier escalation – recognising that waiting for multiple events unnecessarily exposes patients to further risk. By lowering the threshold for intensive management, GOLD aims to reduce exacerbation risk early.
Crucial to this new approach is active case-finding. GOLD 2026 strengthens recommendations for the structured evaluation of at-risk people, particularly those with tobacco exposure, environmental risk factors, or persistent respiratory symptoms.
The guidance contains two new figures detailing risk factors associated with underdiagnosis and a case-finding algorithm to prompt clinicians to consider COPD earlier in the disease course.
The GOLD A, B, C, D classification system has been refined further to emphasise exacerbation risk. The 2026 update continues the use of Group E – a category for patients with elevated exacerbation risk.
The criteria have also been adjusted to reflect real-world evidence that even a single moderate or severe exacerbation prior to maintenance therapy significantly increases the probability of future events.
It is recommended that clinicians actively identify individuals at risk of COPD. Risk factors are defined as age ≥35, exposure to tobacco smoke and indoor or outdoor pollution, genetic factors, prematurity, and early life disadvantages.
GOLD recommends that these patients should be screened using recognised screening questionnaires such as the Lung Function Questionnaire (LFQ), COPD Population Screener Questionnaire (COPD-PS), COPD Diagnostic Questionnaire (CDQ), PUMA or Capture questionnaires etc.
Treatment
The 2026 report separates treatment into initial maintenance therapy (for newly diagnosed patients) and follow-up therapy (for patients already on treatment), simplifying clinical decision points, and reducing ambiguity. The updated algorithms highlight when to consider escalation and how to integrate new evidence into everyday practice.
Among recommendation on pharmacological treatment, long-acting bronchodilators (LABA + LAMA) remain the backbone of maintenance therapy. For patients with one or more moderate exacerbations in the previous year, recommended initial therapy is LABA + LAMA.
The addition of ICS should be considered if the blood eosinophil count is ≥300 cells/µL, and if there is a history of concomitant asthma. ICS should not be used where there is a history of repeated pneumonia or mycobacterium infection, or if the blood eosinophil count is <100 cells/µL.
For patients who do not have a history of exacerbations, a bronchodilator is recommended if mMRC is 0-1 and CAAT is <10. LABA + LAMA is recommended if the mMRC is ≥2 and CAAT is ≥10.
For patients with persistent dyspnoea on LABA + LAMA, consider switching inhaler device or molecules and investigate other causes of dyspnoea, or consider adding ensifentrine. Roflumilast can be considered if FEV1 is <50 per cent and the patient has chronic bronchitis (chronic productive cough for ≥3 months). Azithromycin is the preferred macrolide in former smokers.
GOLD 2026: KEY POINTS
- A diagnosis of COPD should be considered in any patient who has dyspnoea, chronic cough or sputum production, a history of recurrent lower respiratory tract infections and/or a history of exposure to risk factors; spirometry with post-bronchodilator FEV1/FVC <0.7 is mandatory to establish the diagnosis of COPD.
- Additional clinical assessment, including the measurement of lung volumes, diffusion capacity, exercise testing and/or lung imaging may be considered in patients with COPD who have a marked discordance between the level of airflow obstruction and perceived symptoms.
- Concomitant chronic diseases that occur frequently in patients with COPD, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer, should be actively sought and treated appropriately.
- LTOT should not be prescribed routinely for patients with stable COPD or resting or exercise-induced moderate desaturation, but it may improve survival in patients with severe resting chronic hypoxaemia (PaO2 ≤55mmHg or <60mmHg if there is cor pulmonale or secondary polycythaemia).
- Long-term NIV may be of some use in a selected group of patients, particularly those with pronounced daytime hypercapnia and recent hospitalisation.
- In select patients with advanced emphysema refractory to optimised medical care, surgical or bronchoscopic intervention may be beneficial.
- Pharmacological therapy for exacerbations:
- SABAs, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat moderate/severe exacerbations.
- Systemic corticosteroids are recommended for up to five days in patients with moderate/severe exacerbations.
- Antibiotics are recommended for a total of five days in patients with purulent sputum, prior history of lung infections, etc.
- Methylxanthines are not recommended due to increased side effect profiles.
- High flow oxygen systems and mechanical NIV are indicated for patients with COPD and acute respiratory failure.
- In patients with ≥1 moderate or severe exacerbation and elevated blood eosinophil levels, consider the addition of ICSs to a dual bronchodilator regimen.
- Exacerbation recovery time varies (up to 4-6 weeks), with some patients failing to return to their pre-exacerbation functional state.
- Following an exacerbation, the management of COPD and its comorbidities should be reviewed.
- The risk of a major cardiovascular event is significantly increased during and up to one year after a moderate or severe exacerbation.
- In COPD, low BMI (<21kg/m2) is associated with increased risk of death. Obesity (>30kg/m2) is associated with metabolic syndrome and OSA.
- Multiple organ loss of tissue (MOLT) manifested by osteoporosis, sarcopaenia, anaemia and emphysema is associated with poor outcomes. Adequate nutrition, pulmonary rehabilitation and management of MOLT can improve outcomes.
- Virtual and hybrid virtual/in-person care models may offer improved healthcare access, outcomes, and affordability, but use should be based on evidence.
Blood eosinophil count is affirmed as an important biomarker to guide anti-inflammatory therapy. The 2026 guidance summarises the evidence for use of biological therapies, such as dupilumab and mepolizumab, in selected patients with persistent exacerbations and eosinophilic phenotypes. This reflects a move toward phenotype-driven therapy.
Exacerbations
The chapter on exacerbations has been completely rewritten. The updated guidance refines definitions, severity classifications, and management pathways. Emphasis is placed on early detection, accurate diagnosis, and tailored therapy routes that minimise hospitalisation and long-term decline.
Previously, GOLD categorised patients as higher risk only after ≥2 moderate exacerbations or ≥1 severe exacerbation in the previous year. GOLD 2026 states that even a single moderate or severe exacerbation before initiating maintenance therapy now qualifies a patient as high risk and should prompt earlier therapy escalation aimed at preventing further events.
This rewrite also recognises that many hospital admissions previously labelled as COPD exacerbations are driven by other conditions, such as cardiac events, pneumonia or pulmonary embolism, prompting more careful differential diagnosis.
Post-exacerbation follow-up is highlighted as a critical care moment, with structured reassessment of maintenance therapy and secondary prevention measures to prevent recurrence.
Vaccinations are integrated into the preventive care chapter, encouraging clinicians to make immunisation part of routine COPD management, particularly for older adults and those at increased risk of respiratory infections. Updated recommendations include guidance on respiratory syncytial virus (RSV) vaccination for adults, alongside influenza and pneumococcal immunisations.
Other interventions that may reduce the frequency of exacerbations include mucoregulators such as N-acetylcysteine, carbocysteine and erdosteine as well as vitamin D supplementation.
COPD is also associated with airway and lung parenchyma structural changes that provide potential targets for interventional and surgical treatments to alleviate dyspnoea, reduce cough and mucus production, and improve quality of life.
Lung volume reduction surgery improves survival in patients with severe emphysema who have an upper lobe and low post-rehabilitation exercise capacity. In selected cases, bullectomy may be required. In appropriately selected patients with severe COPD, lung transplant has been shown to improve quality of life and functional capacity.
Endobronchial valves, lung coils, and vapour ablation can reduce end-expiratory lung volume and improve lung function. Airway predominant treatments are currently the subject of phase 3 clinical trials.
Clinicians are encouraged to adopt multidisciplinary care strategies and consider how comorbid conditions interact with COPD, for example, how heart failure can mimic or worsen dyspnoea, and how diabetes impacts inflammation and infection risk.
The guidance also states that all clinicians managing patients with COPD should be aware of palliative approaches to symptom control, eg, opiates, neuromuscular electrical stimulation, chest wall vibration, and fans blowing air onto the face can relieve breathlessness.
Morphine may improve health status in patients with COPD. Nutritional supplementation should be considered in malnourished patients with COPD as it may improve respiratory muscle strength and overall health status.
Oxygen may offer some benefit, even if the patient is not hypoxaemic. Long-term oxygen therapy should not be routinely prescribed for patients with stable COPD and resting or exercise-induced moderate desaturation, but it may improve survival in patients with severe resting chronic hypoxaemia (PaO2 ≤55mmHg or <60mmhg if there is cor pulmonale or secondary polycythaemia).
Long-term non-invasive ventilation (NIV) may be of use in selected patients with pronounced daytime hypercapnia and recent hospitalisations.
Indications for high flow oxygen therapy include persistent hypoxaemia, inability to tolerate NIV, contraindication for NIV, weaning off supplemental oxygen after NIV and preventing intubation, as well as for patients with stable COPD at risk of exacerbations.
Acupuncture and acupressure are other non-pharmacological approaches in patients with advanced COPD that may improve breathlessness and quality of life. A multidisciplinary approach combining palliative and respiratory care is recommended for patients with refractory dyspnoea.
Indications for invasive mechanical ventilation include the following:
- Persistent life-threatening hypoxaemia despite HFNT or NIV
- Unable to tolerate HFNT and/or NIV
- Following respiratory or cardiac arrest
- Diminished consciousness
- Massive aspiration or persistent vomiting
- Persistent inability to remove respiratory symptoms
- Severe haemodynamic instability
- Severe ventricular or supraventricular arrythmias.
Technology
A new addition to the guidance is a chapter on artificial intelligence and emerging technologies in COPD care. GOLD acknowledges the rapid evolution of digital health tools, AI decision support systems, remote monitoring platforms, and computational patient profiles.
While cautioning that these technologies require careful clinical validation, the report recognises the potential benefits of AI-assisted spirometry interpretation to reduce subjectivity and speed diagnosis, and telemonitoring using wearable technology.
The 2026 update also notes the opportunities provided by predictive models for exacerbation risk based on longitudinal data, and decision support tools to integrate multimorbidity management and personalised therapy pathways. GOLD does not mandate any specific AI tool.
Summary
GOLD 2026 reframes COPD as a modifiable, biologically active disease and sets a new standard for pro-active management. Key recommendations include actively case-finding at-risk patients rather than waiting for severe symptoms.
The 2026 update encourages clinicians to go beyond single point assessments, like spirometry alone,
and adopt longitudinal markers of disease course, including frequency of exacerbations, symptom trends, and serial lung function. This supports a more dynamic view of COPD, adjusting therapy in response to changes in disease activity rather than static thresholds.
