Grades are shown as the source states them. GOLD publishes a strategy report rather than a graded guideline. Its evidence levels (A to D) appear only in the full report, so no grades are shown here.
Key recommendations
Think of COPD in anyone with breathlessness, chronic cough or sputum, recurrent chest infections, or exposure to risk factors, and confirm it with spirometry: a post-bronchodilator FEV1/FVC below 0.7.
Chapter 2: key pointsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Support everyone who smokes to quit at every opportunity; counselling combined with medication is the most effective approach.
Chapter 3: smoking cessationGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Start treatment by GOLD group. Group A: a bronchodilator, long-acting if available and affordable. Group B: LABA+LAMA. Group E: LABA+LAMA, or LABA+LAMA+ICS if blood eosinophils are 300 cells/µL or more. LABA+ICS alone is not encouraged, and everyone should have a short-acting reliever.
Chapter 3: initial pharmacological managementGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Check inhaler technique and adherence at every review, and choose a device the person can actually use.
Chapter 3: key pointsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Pulmonary rehabilitation (exercise training with education) improves exercise capacity, symptoms and quality of life at every level of severity.
Chapter 3: key pointsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Offer all recommended vaccines in line with local guidance: influenza, pneumococcal (PCV20 or PCV21 preferred), RSV, COVID-19, Tdap if not given in adolescence, and shingles.
Chapter 3: vaccinationsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Diagnosis
COPD is a heterogeneous lung condition with chronic respiratory symptoms caused by abnormalities of the airways and/or alveoli that produce persistent, often progressive, airflow obstruction.
Chapter 1: key pointsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Using the fixed FEV1/FVC ratio of 0.7 may over-diagnose COPD in older people compared with the lower limit of normal, particularly in mild disease.
Chapter 2: spirometric criteriaGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Initial assessment covers the severity of airflow obstruction, the impact of symptoms (mMRC or CAAT score) and the risk of future exacerbations, admissions and death.
Chapter 2: key pointsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Tobacco is not the only cause. In low- and middle-income countries up to 60–70% of COPD occurs in non-smokers, linked to biomass smoke, outdoor air pollution, occupational dusts, and previous tuberculosis.
Environmental risk factors; InfectionsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2023
Investigations
Repeat spirometry at least once a year, without stopping bronchodilators beforehand.
Chapter 3: follow-up reviewGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Use the blood eosinophil count to guide inhaled corticosteroids: benefit may be seen from 100 cells/µL upwards and is more likely the higher the count.
Chapter 3: follow-up pharmacological managementGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Use pulse oximetry in anyone with signs of respiratory or right heart failure, and measure arterial blood gases if saturation is 92% or below.
Chapter 2: oximetry and arterial blood gas measurementGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Actively look for coexisting conditions — cardiovascular disease, muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety and lung cancer — because they affect health, admissions and survival independently of COPD severity.
Chapter 2: key pointsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Offer annual low-dose CT screening for lung cancer to people with COPD and a smoking history, as for the general population; there is no evidence to screen when COPD is not related to smoking.
Chapter 5: key pointsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Treatment
At follow-up, review symptoms and exacerbations, assess inhaler technique, adherence and non-drug measures, then adjust. For persistent breathlessness on one long-acting bronchodilator, move to LABA+LAMA; if still breathless, consider another device or molecule, rehabilitation, ensifentrine where available, and other causes of breathlessness.
Chapter 3: follow-up pharmacological managementGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
For exacerbations on one bronchodilator, move to LABA+LAMA; after a moderate or severe exacerbation on LABA+LAMA, add an ICS. If exacerbations continue, consider azithromycin in people who do not smoke (weighing antimicrobial resistance), roflumilast if FEV1 is below 50% with chronic bronchitis and a previous severe exacerbation, or a biologic (dupilumab or mepolizumab) if eosinophils are 300 cells/µL or more on triple therapy.
Chapter 3: follow-up pharmacological managementGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Do not withdraw the ICS from triple therapy unless it was started inappropriately, has not helped, or causes significant side effects or recurrent or severe pneumonia. With eosinophils of 300 cells/µL or more, withdrawal is more likely to bring on exacerbations.
Chapter 3: follow-up pharmacological managementGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Long-term oxygen is indicated for PaO2 of 55 mmHg (7.3 kPa) or less, or SaO2 of 88% or less, confirmed twice over three weeks; or PaO2 55–60 mmHg with pulmonary hypertension, oedema suggesting heart failure, or polycythaemia (haematocrit above 55%). It does not help moderate desaturation. Reassess after 60–90 days.
Chapter 3: oxygen therapyGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Home non-invasive ventilation may help selected people with marked daytime hypercapnia after a recent admission. CPAP for coexisting obstructive sleep apnoea improves survival and reduces admissions.
Chapter 3: ventilatory supportGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
If asthma coexists, treat according to asthma guidelines; an inhaled corticosteroid is then essential.
Chapter 3: initial pharmacological managementGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
For breathlessness despite optimal treatment, use bronchodilators, self-management and rehabilitation; opioids, a fan blowing on the face, neuromuscular electrical stimulation and chest wall vibration can also help. There is no evidence of benefit from benzodiazepines.
Chapter 3: palliative treatment of dyspneaGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Important geriatric considerations
GOLD adopts the “4Ms” for older people with COPD: Mentation (especially depression and dementia), Mobility (balance, frailty, six-minute walk), Medications (more than 90% have polypharmacy) and Morbidities.
Chapter 5: 4Ms approachGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Frailty is more common in COPD and is associated with death, exacerbations and hospital admission.
Chapter 5: COPD, frailty and multimorbidityGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Inhaler errors become more common with age, mainly through cognitive impairment, poor dexterity or hand strength, tremor and low inspiratory flow. Add a spacer if pMDI technique is doubtful, although some older people find spacers hard to use; asking the person to demonstrate (teach-back) works well.
Chapter 3: choice and use of inhaler devicesGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Treat other conditions as usual regardless of COPD, keep regimens simple and minimise polypharmacy. Beta-1-selective blockers are recommended for cardiovascular indications such as heart failure, but not to prevent exacerbations.
Chapter 5: key points; cardiovascular diseasesGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Even short courses of systemic corticosteroids are linked with pneumonia, sepsis and death, so keep them for significant exacerbations. Repeated courses also increase the risk of osteoporosis and should be avoided where possible.
Chapter 4: glucocorticoids; Chapter 5: osteoporosisGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
The risk of a major cardiovascular event rises during, and for up to a year after, a moderate or severe exacerbation.
Chapter 5: key pointsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Extreme temperatures increase the risk of death. In cold weather keep bedrooms above 18°C; in heatwaves stay hydrated and aim for living spaces below 32°C and bedrooms below 24°C.
Chapter 3: climate change and COPDGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Kidney impairment is common in COPD (17–20% of those over 70), and because sarcopenia is frequent, a normal creatinine can hide a low GFR.
Chapter 5: renal failureGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
RSV vaccination is recommended for everyone aged 75 or over not previously vaccinated, and for those aged 50–74 with a risk factor such as chronic lung or heart disease, immune compromise or living in a care home. High-dose or adjuvanted influenza vaccines are acceptable options for older adults.
Chapter 3: vaccinationsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Drug doses
Exacerbation, first-line bronchodilators: a short-acting beta-agonist with or without a short-acting antimuscarinic, by nebuliser (one dose hourly for 2–3 doses) or pMDI (1–2 puffs hourly for 2–3 doses), then every 2–4 hours according to response. Avoid high doses, and drive nebulisers with air rather than oxygen.
Chapter 4: bronchodilatorsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Systemic corticosteroid: 40 mg prednisone-equivalent daily for 5 days; oral is as effective as intravenous.
Chapter 4: glucocorticoidsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Antibiotics when sputum purulence is present with at least one other of increased breathlessness, fever or sputum volume; after a previous positive sputum culture; or when ventilation is needed. Usual empirical choices are amoxicillin–clavulanate, a macrolide or a tetracycline (a quinolone in selected patients), guided by local resistance; 5 days or fewer for outpatients.
Chapter 4: antibioticsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Titrate supplemental oxygen during an exacerbation to a saturation of 88–92%, checking blood gases for carbon dioxide retention in severe exacerbations.
Management of ECOPD: oxygen therapyGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2023
When to refer
Consider hospital admission for severe symptoms (sudden worsening breathlessness at rest, fast breathing, low saturation, confusion or drowsiness), acute respiratory failure, new signs such as cyanosis or oedema, failure of initial treatment, serious comorbidity such as heart failure or a new arrhythmia, or inadequate support at home.
Management of ECOPD: treatment settingGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2023
After an admission, review within a month where possible and again at three months. Starting rehabilitation within four weeks of discharge is associated with better quality of life and exercise capacity.
Chapter 4: hospital discharge and follow-upGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
For advanced emphysema despite optimal treatment, refer for assessment for surgical or bronchoscopic lung volume reduction.
Chapter 3: key pointsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Palliative approaches are effective for symptoms in advanced COPD, and refractory breathlessness may be best managed by an integrated palliative and respiratory care service.
Chapter 3: key points; supportive, palliative, end-of-life and hospice careGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Red flags
Pneumonia, pulmonary embolism, acute heart failure and pneumothorax can mimic or worsen an exacerbation, so look for them.
Chapter 4: key pointsGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
In the emergency department, give controlled oxygen to hypoxaemic patients and assess whether the exacerbation is life-threatening; non-invasive ventilation is the first-line treatment for acute respiratory failure.
Chapter 4: treatment setting; ventilatory supportGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
People admitted with an exacerbation are at increased risk of venous thromboembolism (pulmonary embolism in up to 5.9%), so give thromboprophylaxis.
Chapter 4: adjunct therapiesGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Readmission within 30 days affects 30–50% of people after an exacerbation admission, and about half die within five years, so plan discharge and prevention carefully.
Chapter 4: hospital discharge and follow-up; prognosisGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
Recent updates
GOLD 2026: a single moderate exacerbation should now prompt consideration of treatment escalation, with the aim of low disease activity — no exacerbations, no worsening of symptoms and no accelerated loss of lung function.
Key changes summary; Chapter 3: disease activityGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026
GOLD 2026 also added an evidence summary for biologics, completely revised the chapters on exacerbations and on multimorbidity, and updated the RSV and influenza vaccination advice.
Key changes summaryGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2026