Rectifying COPD management: A critical analysis of the GOLD strategy

The Global Initiative for Obstructive Lung Disease (GOLD) has greatly contributed to the management of chronic obstructive pulmonary disease (COPD). However, several important issues persist. The initial conception of chronic bronchitis as a short-term illness caused by 1950s air pollution differs significantly from the current understanding of COPD. COPD and asthma are often diagnosed subjectively due to the lack of definitive diagnostic criteria. Asthma patients who lack classic features may be misclassified as having chronic bronchitis, contributing to diagnostic overlap and unnecessary heterogeneity. The inclusion of asthma patients in COPD studies may have introduced significant bias, leading to misguided management recommendations. Notably, studies that attempted to minimize asthma misclassification—such as by excluding patients with elevated blood eosinophil counts—demonstrated more favourable outcomes in the absence of inhaled corticosteroids compared to studies that applied no such exclusion criteria. COPD patients with blood eosinophilia respond to inhaled corticosteroids precisely because they likely have asthma. Bronchodilator reversibility and airway hyperresponsiveness tests have limited utility in ruling out asthma. Despite their limitations, lung function tests remain central to the assessment and management of COPD. Their clinical value is limited by measurement variability and controversies regarding their interpretation. The current “combined assessment” tool may have limited validity, particularly as treatment strategies have become increasingly standardized, emphasising early initiation of dual bronchodilators and avoidance of corticosteroids. Existing strategy documents remain subject to future revisions, as has occurred with previous versions. Realising their full potential requires critical engagement and thoughtful revision, particularly in addressing persistent areas of controversy.