COPD: the GOLD 2026 Report

In a major revision to its annual report on chronic obstructive pulmonary disease (COPD), GOLD has made a number of important changes, including earlier escalation of therapy following even one exacerbation. Taken as whole, the 2026 report is an important part of GOLD’s ongoing commitment to reduce premature mortality by a third by 2030

COPD is now one of the top three causes of death worldwide, a major cause of chronic morbidity and mortality: many people suffer from COPD for years and then die prematurely from either the disease itself, or its complications. The burden of COPD is predicted to continue to increase because of persistent exposure to risk factors and the ageing of the population.

Studies suggest that up to 70% of adults with COPD remain undiagnosed. These people experience poor quality of life, and may have a greater symptom burden than those with a confirmed diagnosis. Exacerbations and pneumonia are also more frequent in undiagnosed COPD, and the risk of death from respiratory causes is four times greater than in people without COPD.

COPD may go undiagnosed for a variety of reasons. Patient-related factors include:

• Under-recognition or under-reporting of symptoms
• Adaptation of activities to minimise breathlessness, and
• Milder disease or impairment in undiagnosed people.

Healthcare provider-related factors include:

• Poor understanding of the diagnostic criteria for COPD
• Inadequate training in the use and interpretation of spirometry, and
• Inadequate investigation and referral to specialists for people presenting with respiratory symptoms.

Among the healthcare system-related factors are poor access to spirometry, and disparities in access to healthcare (even in high-income countries).

Rates of diagnosis could be improved by screening or case finding. However, screening of mostly asymptomatic individuals with spirometry is expensive and yields relatively few new diagnoses.

In contrast, case-finding targets people with unexplained respiratory symptoms or specific risk factors for COPD. Active case-finding means proactively searching for people at higher risk, such as unexplained breathlessness or a >20-year pack-year history of smoking, or history of recurrent chest infections, using questionnaires such as CDQ or CAPTURE. People with a positive response should be offered targeted spirometry. Systematic active case-finding in primary care by postal questionnaire has been found to be effective, with a small but significant effect on increasing rates of diagnosis and on clinicians’ clinical actions.

Opportunistic case-finding involves identifying individuals who attend for healthcare for other reasons, for example, performing diagnostic spirometry in individuals who present for lung cancer screening. Taking advantage of lung cancer screening to screen for COPD may be particularly useful as lung cancer and COPD share common risk factors, and COPD is an independent risk factor for lung cancer. Studies have shown that spirometry at lung cancer screening identified airflow obstruction in 34-47%, and emphysema in 68-73% of individuals.

DISEASE ACTIVITY

In chronic inflammatory diseases, 'disease activity' describes the biological processes that drive disease outcomes and which can often be managed or reversed with proper treatment. Without effective treatment, these processes may cause disease progression, leading to lasting damage and loss of function. In COPD, anti-inflammatory medications can help lower disease activity and prevent organ damage. Additionally, lifestyle changes such as smoking cessation and pulmonary rehabilitation can also help reduce disease activity.

Achieving low disease activity – also described as disease stability – is a key treatment target in COPD, and is characterised by no exacerbations, no worsening of symptoms, and no acceleration in loss of lung function. Disease control– no exacerbations, no worsening of symptoms, and symptoms below a defined threshold – may be difficult to achieve in patients with later stage disease, improvements in disease activity are possible with combinations of pharmacological and non-pharmacological treatment.

THE PHARMACOLOGICAL MANAGEMENT CYCLE

The criteria for defining GOLD categories (A, B and E) have been updated due to emerging evidence from observational studies that even one moderate or severe exacerbation before initiating maintenance pharmacological therapy increases the risk of further exacerbations, and the risk increases if exacerbations are frequent or severe (Figure 1).

• All patients in group A should be offered either a short- or long-acting bronchodilator (SABA or LABA). LABA is the preferred option except in people with very occasional breathlessness
• Patients in group B should be offered a LABA+LAMA combination. Patients in this group are likely to have comorbidities that may add to their symptom burden and affect their prognosis. These should be investigated and treating according to their respective guidelines.
• Patients in group E should be offered LABA+LAMA+ICS (if their blood eosinophil count is ≥ 300 cells/μl) (Table 1).
• Patients with concurrent asthma should be treated as patients with asthma, with mandatory use of ICS.

Treatment should be tailored according to the level of the patient’s symptoms and risk of exacerbation, and escalated on the basis of predominant symptoms of breathless and exercise limitation, and continuing exacerbations while on maintenance therapy. Studies suggest that one moderate or severe exacerbation increases the risk of further exacerbations,

Recommendations for initial therapy are shown in Figure 2. Treatment should be based on the patient’s GOLD group, and patients should be given advice on self-management of breathlessness, and given a written action plan.

Reviews should take place more frequently for people with severe disease, and at longer intervals for those with less severe disease. Assessment should include:

• Current level of symptoms (using either CAAT^TM or mMMR scores)
• Exacerbation frequency
• The effect of treatment
• Possible adverse events
• Re-assessment of comorbidities
• Inhaler technique
• Adherence to prescribed treatment (inhaled therapy and non-pharmacological)
• Smoking status, and
• Continued exposure to risk factors.

Follow-up treatment should be based on the degree of the breathlessness and exacerbations (Figure 3). Adjust treatment, either escalating or de-escalating, according to symptoms and exacerbation frequency. Consider switching inhaler device or molecules in the same class if required. Review clinical response after any change in treatment.

VACCINATIONS

Recommendations for vaccinations for people with COPD have been updated to include RSV (respiratory syncytial virus).

• Annual flu vaccination
• Annual COVID-19 vaccination
• One-off dose of 21-valent pneumococcal vaccine
• RSV vaccination for people aged ≥50 years and/or with chronic heart or lung disease
• dTaP/dTPa to protect against pertussis (and tetanus and diphtheria) for people with COPD who were not vaccinated in adolescence
• Zoster vaccine to protect people with COPD aged >50 years against shingles

MULTIMORBIDITY

Multimorbidity – two or more additional long term conditions – is common in people with COPD. The most common include:

• Hypertension
• Ischaemic heart disease
• Heart failure
• Atrial fibrillation
• Lung cancer
• Obesity
• Frailty
• Malnutrition
• Gastroesophageal reflux disease
• Depression
• Anxiety

These conditions complicate the management of COPD, but are often underdiagnosed and undertreated. Clinicians should actively search for the presence of comorbities in patients with COPD, and treat them according to the condition-specific guidelines.

Some comorbidities arise independently of COPD, but others either share the same pathological pathways, or increase poor outcomes in the other – i.e. COPD is negatively affected by comorbid conditions or adversely affects the outcomes of other conditions. For example, people with heart failure have greater morbidity and mortality when COPD is present than when it is not.

Comorbidities often present as clusters in patients with COPD.

• Mental cluster includes depression and anxiety, and cognitive impairment
• Respiratory cluster comprises lung cancer, asthma, sleep disordered breathing, interstitial lung disease and bronchiectasis
• Cardiovascular cluster includes hypertension, heart failure, coronary artery disease, arrythmia, pulmonary hypertension
• Metabolic diseases cluster covers diabetes, fatty liver, obesity and gastroesophageal reflux disease
• Multiple organs loss of tissue (MOLT) cluster comprises osteoporosis, sarcopenia, renal failure, anaemia

The association between lung cancer and COPD is well-established. Both diseases share more than tobacco smoking as their common origin, and genetic susceptibility, chronic lung inflammation and abnormal lung repair mechanisms present in COPD are important contributors to the development of lung cancer. The most effective preventive measures for both conditions are smoking prevention and cessation.

GOLD recommends a ‘4M’ approach to the management of multimorbidities.

Mentation – Establish the patient’s life goals, screen for depression, anxiety and cognitive impairment

Mobility – Check for balance and exercise capacity

Morbidities – Identify and treat

Medications – Review, and if necessary, establish a safe plan for their use. Adjust dose or deprescribe if appropriate

MANAGEMENT OF EXACERBATIONS

An exacerbation of COPD is an acute event with symptoms worsening over time (between a few days and two weeks). Key features include increased breathlessness and/or cough and sputum production, sometimes accompanied by rapid breathing and/or heart rate. They are often associated with increased airway inflammation, mucus production and increased gas trapping. Sputum may be purulent.

Exacerbations are important events because they have a negative affect on health status, and worsen airflow obstruction and disease progression, and increase the risk of hospitalisation (and readmission) and mortality.

Most exacerbations are caused by infections, either viral or bacterial, or by environmental pollutants. However, other conditions such as pneumonia, pulmonary embolism, acute heart failure and pneumothorax can cause similar symptoms, and the exact cause of an exacerbation may remain unknown.

The severity of COPD exacerbations is classified as mild, moderate or severe, according to new criteria proposed in the current GOLD report.

Mild

• Dyspnoea VAS < 5
• Respiratory rate < 24 breaths/minute
• Heart rate <95 BPM
• Resting oxygen saturation (SaO₂) ≤92% breathing ambient air (or usual prescribed oxygen) AND change ≤ 3% (when known)
• CRP <10 mg/l (if available)

Moderate (at least three of five)

• Dyspnoea VAS ≥ 5
• Respiratory rate ≥ 24 breaths/minute
• Heart rate ≥ 95 BPM
• Resting SaO₂ <92% when breathing ambient air (or usual prescribed oxygen) AND change > 3% (when known)
• CRP ≥10 mg/l (if available)

Severe

• Dyspnoea, respiratory rate, heart rate, SaO2 and CRP same as moderate
• If obtained, arterial blood gas (ABG) may show hypoxemia (PaO₂ ≤ 60 mmHg) and/or hypercapnia and acidosis (PaO₂ 45 mmHg and pH <7.35)

Abbreviations: BPM, beats per minute; CRP, c-reactive protein; SaO₂, oxygen saturation; VAS, visual analogue scale.

In primary care, the severity of an exacerbation can be assessed on the basis of the VAS 0 – 10 dyspnoea scale, where 0 equals ‘not at all breathless’ and 10 equals the ‘worst breathlessness ever experienced’, respiratory rate, heart rate an oxygen saturation. Worsening of breathlessness, particularly if associated with cough, purulent sputum, and difficulty sleeping because of these symptoms, can be diagnosed as an exacerbation. In patients with worsening of respiratory symptoms but without other COPD symptoms, consider other coexisting conditions.

Patients with COPD are at increased risk of respiratory viral infections, bacterial infections, pneumonia, decompensated heart failure, heart attack and arrhythmias, and pulmonary embolism: these conditions may mimic or worsen exacerbations, and increase the risk of a cardiovascular event. This risk remains elevated for up to 12 months after the initial exacerbation.

When deciding on where the exacerbating patient should be managed, consider not only the severity of the exacerbation, but also how compromised the patient is. Assess:

• Underlying COPD severity
• Presence and severity of comorbidities
• Mental status, and
• Social factors, including the availability of home support.

Indications for hospitalisation include signs and symptoms of respiratory failure, failure of the exacerbation to respond to initial management, presence of serious comorbidities e.g., heart failure, cardiac arrhythmia, and insufficient home support. Patients with a mild exacerbation, minimal comorbid involvement and good home support can be managed at home.

The most significant predictors of a COPD exacerbation include a history of previous exacerbations, impaired lung function (FEV1) and the number of COPD maintenance medications. Even one exacerbation in the year prior to diagnosis of COPD increases the risk of exacerbations in the next 12 months, and this risk increases substantially if there have been two or more previous exacerbations.

The long-term prognosis following hospitalisation for a COPD exacerbation is poor, with a five-year mortality rate of about 50%.

Management of exacerbations

GOLD recommends:

• Short-acting inhaled beta-agonists (SABA), with or without short-acting anticholinergics as initial treatment of an acute exacerbation
• Systemic corticosteroids for 5 days to improve lung function and oxygenation, and to shorten recovery time
• Antibiotics (5 days) for patients with purulent sputum, prior positive sputum bacteria culture (or requiring mechanical ventilation)
• High flow oxygen as first line method of ventilation in COPD patients with acute respiratory failure.

Follow-up

Readmission occurs in 30%–50% of patients within 30 days of discharge after hospitalisation for a COPD exacerbation.

On discharge patients should be treated with LABA + LAMA, + ICS if blood eosinophils are raised. Inhaler technique should be reassessed, and patients should understand when to stop acute medications (oral corticosteroids, antibiotics). All patients should be provided with a management plan.

Between 1 and 4 weeks post-discharge, patients should be seen for the following assessments:

• Evaluation of their ability to cope in their usual environment
• Review of understanding of their treatment regimen
• Reassessment of inhaler technique
• Reassessment of the need for long-term oxygen
• Capacity for physical activity and eligibility for pulmonary rehabilitation
• Review and documentation of symptoms (CAAT or mMRC)
• Status of comorbidities

These assessments should be repeated at 12 – 16 weeks after hospital discharge, and in addition, lung function should be assessed (spirometry).

After an acute exacerbation, steps should be taken to prevent further exacerbations:use of LABA+LAMA+ICS, smoking cessation, immunisation against flu, pneumonia, RSV, and pulmonary rehabilitation have been shown to improve function and reduce subsequent exacerbations.

Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2026 Report; November 2026. https://goldcopd.org/2026-gold-report-and-pocket-guide/