GOLD 2026 COPD Report: A Practical Guide to Diagnosis, Assessment and Management

What clinicians need to know about diagnosing COPD, choosing initial therapy, preventing exacerbations and escalating treatment

The 2026 GOLD Report is the sixth major revision of the Global Strategy for the Diagnosis, Management, and Prevention of COPD. It incorporates 338 new references from peer-reviewed research published between January 2024 and July 2025.

This is more than a routine annual update. GOLD has revised the ABE classification, introduced the concept of disease activity, clarified the distinction between initial and follow-up pharmacological treatment, incorporated biologic therapies, comprehensively revised exacerbation and multimorbidity management, and added a chapter on artificial intelligence and emerging technologies.

Why is GOLD 2026 important?

COPD remains a major global cause of morbidity and mortality. More than 3 million people died from COPD in 2021, accounting for approximately 5% of global deaths, and nearly 90% of COPD deaths occur in low- and middle-income countries.

The clinical emphasis of GOLD is increasingly broader than simply improving FEV₁. Treatment aims to address two parallel goals: reducing current symptoms and their impact, and reducing future adverse events, particularly exacerbations.

For 2026, exacerbation prevention becomes even more prominent: a single moderate exacerbation is now considered clinically meaningful when assessing future risk.

What has changed in GOLD 2026?

The principal changes highlighted by GOLD include:

• revised screening and case-finding guidance
• updated influenza and RSV vaccination recommendations
• modification of the GOLD ABE classification
• introduction of disease activity
• clearer separation of initial versus follow-up pharmacological treatment
• incorporation of evidence for biologic therapy
• complete revision of the exacerbation chapter
• complete revision of multimorbidity management
• a new chapter on artificial intelligence and emerging technologies.

The change most likely to affect routine prescribing is the revised definition of Group E.

How is COPD diagnosed?

COPD should be considered in patients with chronic respiratory symptoms such as dyspnoea, cough, sputum production or recurrent exacerbations, particularly when relevant environmental or host risk factors are present.

However, symptoms and exposure history alone do not establish the diagnosis.

COPD is confirmed by post-bronchodilator spirometry showing:

FEV₁/FVC <0.70.

GOLD retains this fixed-ratio criterion for 2026.

Importantly, bronchodilator reversibility should not be used to distinguish COPD from asthma or to predict long-term response to bronchodilators or corticosteroids.

COPD should also not be considered exclusively a smoking-related disease. GOLD emphasises lifetime gene–environment interactions, including tobacco, household and outdoor air pollution, occupational exposures, abnormal lung development and accelerated lung ageing.

Should clinicians screen everyone with spirometry?

No.

GOLD does not recommend screening spirometry in asymptomatic people without significant tobacco or other COPD risk exposures.

Instead, GOLD supports active case-finding among patients with symptoms and/or relevant risk factors. Examples include unexplained dyspnoea, substantial smoking exposure, recurrent chest infections or relevant early-life events. Positive case-finding should ultimately lead to diagnostic spirometry.

This distinction matters clinically: GOLD is advocating targeted earlier diagnosis rather than population-wide spirometric screening.

How should confirmed COPD be assessed?

Assessment should answer several separate questions:

• How severe is the airflow obstruction?
• How symptomatic is the patient?
• Have exacerbations occurred?
• Is an ICS-responsive phenotype likely?
• Are important comorbidities present?

Airflow obstruction remains graded according to FEV₁:

However, spirometric grade does not determine the ABE treatment group. Initial pharmacological treatment is driven principally by symptoms and exacerbation history. The ABE assessment illustrated in Figure 2.13 of the report separates spirometric severity from the clinical grouping used to guide initial treatment.

Symptoms can be assessed with the modified Medical Research Council (mMRC) dyspnoea scale or Chronic Airways Assessment Test (CAAT™).

What is the major change to the GOLD ABE classification?

This is one of the most clinically important changes in 2026.

Previously, patients generally entered Group E after ≥2 moderate exacerbations or ≥1 severe exacerbation requiring hospitalisation.

GOLD 2026 now recognises that observational studies show an increased risk of subsequent events even after one moderate or severe exacerbation.

Therefore:

The report's revised ABE figure explicitly places one or more moderate or severe exacerbations in the previous year in Group E.

This lowers the threshold at which exacerbation prevention becomes a central treatment objective.

What does GOLD mean by “disease activity”?

GOLD 2026 introduces a dedicated section on disease activity, reflecting the idea that COPD should not be viewed simply as a static level of airflow obstruction.

The emerging objective is a state of low disease activity, particularly characterised by the absence of exacerbations. GOLD explicitly links the new one-exacerbation threshold to considering escalation with the aim of achieving no exacerbations.

This concept remains evolving, but it reinforces an important clinical message: recurrent acute events should not simply be accepted as an inevitable feature of COPD.

What initial inhaled treatment should be prescribed?

GOLD makes an important distinction between initial treatment in treatment-naïve patients and follow-up treatment in patients already receiving maintenance therapy.

Group A

Offer a bronchodilator according to its effect on breathlessness.

A long-acting bronchodilator is preferred when available and affordable, except when breathlessness is very occasional. Continue treatment if clinical benefit is documented.

Group B

Start:

LABA + LAMA

Dual long-acting bronchodilation is recommended over monotherapy, provided availability, cost and adverse effects do not preclude its use.

Group E

Preferred initial treatment:

LABA + LAMA

If the blood eosinophil count is ≥300 cells/µL, consider:

LABA + LAMA + ICS

GOLD describes initial triple therapy at this eosinophil threshold as a practical recommendation, acknowledging that direct evidence for initiating triple therapy in newly diagnosed treatment-naïve patients is lacking.

LABA + ICS is not encouraged in COPD. If ICS is indicated, triple therapy is preferred.

If COPD and asthma coexist, treatment should primarily follow asthma guidance and ICS is mandatory.

A rescue short-acting bronchodilator should be available to all patients for immediate symptom relief.

How should treatment be adjusted at follow-up?

Do not simply continue escalating inhalers without first asking why treatment is failing.

GOLD uses a:

Review → Assess → Adjust

approach.

Review symptoms and exacerbations. Assess inhaler technique, adherence and non-pharmacological management. Then adjust treatment if necessary, followed by reassessment of the response and adverse effects.

The follow-up algorithm is built around two major treatable traits:

persistent dyspnoea and continued exacerbations.

Importantly, the patient's original A, B or E category no longer determines the follow-up pathway.

What if dyspnoea persists?

For persistent breathlessness or exercise limitation despite one long-acting bronchodilator:

LABA or LAMA → LABA + LAMA

If symptoms remain despite dual bronchodilation, clinicians should reconsider the problem rather than automatically adding ICS.

Options include:

• checking adherence and inhaler technique
• switching inhaler device or molecules
• increasing non-pharmacological treatment, particularly pulmonary rehabilitation
• considering ensifentrine, where available
• investigating other causes of dyspnoea, including cardiovascular disease, deconditioning and other pulmonary disorders.

ICS is therefore principally an exacerbation-prevention strategy, not a treatment for persistent dyspnoea alone.

What if exacerbations continue?

The 2026 follow-up pathway now responds to one or more moderate or severe exacerbations.

On bronchodilator monotherapy:

→ escalate to LABA + LAMA

If a moderate or severe exacerbation occurs despite LABA + LAMA:

→ consider LABA + LAMA + ICS

The likelihood of benefit from ICS begins to become clinically relevant at blood eosinophils ≥100 cells/µL, with increasing benefit at higher eosinophil counts.

This is important: 300 cells/µL is not a universal threshold below which ICS cannot work. Rather, eosinophil response exists along a continuum.

How should blood eosinophils guide ICS treatment?

Blood eosinophils are used as a biomarker predicting the magnitude of benefit from ICS for exacerbation prevention.

In practical terms:

Other factors matter.

GOLD's Figure 3.10 indicates that a history of hospitalisation for COPD exacerbation, ≥2 moderate exacerbations per year, eosinophils ≥300 cells/µL or concomitant asthma favour ICS-containing treatment. Repeated pneumonia, eosinophils <100 cells/µL and a history of mycobacterial infection argue against ICS use.

The decision should therefore combine exacerbation history, eosinophils and clinical risk, rather than use eosinophils in isolation.

When should biologic therapy be considered?

Biologics now have a clearer place in the GOLD treatment pathway.

For patients continuing to exacerbate despite LABA + LAMA + ICS, with blood eosinophils ≥300 cells/µL, GOLD advises considering:

• dupilumab in patients with chronic bronchitis
• mepolizumab in patients with or without chronic bronchitis.

This is not biologic therapy for COPD generally.

The dupilumab trials enrolled patients with chronic bronchitis, GOLD 2–3 airflow obstruction, eosinophils ≥300 cells/µL and ≥2 moderate or ≥1 severe exacerbation in the preceding year despite triple therapy. Dupilumab reduced exacerbations and improved lung function and health status over 52 weeks.

Mepolizumab evidence similarly comes from highly selected patients with eosinophils ≥300 cells/µL and recurrent exacerbations despite triple therapy.

These therapies should therefore be viewed as add-on options for selected exacerbation-prone eosinophilic COPD, rather than substitutes for appropriate inhaled therapy.

What other options are available for persistent exacerbations?

If exacerbations continue despite appropriate inhaled treatment, GOLD identifies additional phenotype-directed options.

Azithromycin may be considered particularly in patients who are not currently smoking, while weighing antimicrobial resistance.

Roflumilast may be considered particularly in patients with:

• FEV₁ <50% predicted
• chronic bronchitis
• a history of severe exacerbation/hospitalisation.

ICS withdrawal from triple therapy should not be routine. GOLD suggests considering withdrawal when ICS was started inappropriately, has produced no response, or causes significant adverse effects or severe/recurrent pneumonia. Withdrawal is more likely to precipitate exacerbations when eosinophils are ≥300 cells/µL.

What non-pharmacological treatment should every clinician remember?

Drug therapy is only one component of COPD management.

GOLD emphasises a smoke-free environment, physical activity, vaccination and pulmonary rehabilitation as part of comprehensive management.

Smoking cessation

Smoking cessation has the greatest capacity to influence the natural history of COPD, improves symptoms and reduces exacerbation frequency. Combining behavioural support with pharmacotherapy is more effective than either approach alone.

Vaccination

Vaccination should follow relevant local guidance. GOLD specifically discusses:

• influenza
• pneumococcal vaccination
• RSV
• COVID-19
• Tdap where indicated
• shingles vaccination.

GOLD 2026 includes updated information on both influenza and RSV vaccination.

Pulmonary rehabilitation

Pulmonary rehabilitation improves exercise capacity, symptoms and quality of life. Patients with substantial symptom burden and/or exacerbation risk, particularly Groups B and E, should be encouraged to participate in structured programmes.

Who should receive long-term oxygen therapy?

LTOT is indicated in stable COPD when severe chronic hypoxaemia is documented:

• PaO₂ ≤55 mmHg (7.3 kPa) or SaO₂ ≤88%, confirmed twice over three weeks; or
• PaO₂ 55–60 mmHg (7.3–8.0 kPa) or SaO₂ 88% when pulmonary hypertension, peripheral oedema suggesting heart failure, or polycythaemia with haematocrit >55% is present.

LTOT improves survival in severe resting hypoxaemia.

It should not be routinely prescribed for moderate resting or exercise-induced desaturation, where sustained mortality or hospitalisation benefit has not been demonstrated.

Patients started on LTOT should be reassessed after 60–90 days.

How does GOLD 2026 define a COPD exacerbation?

An exacerbation is an acute event characterised by worsening dyspnoea and/or cough and sputum over a few days, up to 14 days, sometimes accompanied by tachypnoea or tachycardia.

Do not assume every episode of worsening breathlessness is COPD.

Important mimics or contributors include:

• pneumonia
• pulmonary embolism
• acute heart failure
• myocardial infarction or arrhythmia
• pneumothorax.

This is especially important because cardiovascular risk rises substantially during and following COPD exacerbations and may remain increased for months afterwards.

How is exacerbation severity assessed?

GOLD uses the Rome classification, which evaluates the patient at presentation rather than retrospectively defining severity according to treatment or hospitalisation.

Moderate exacerbation requires at least three of five criteria:

• dyspnoea VAS ≥5
• respiratory rate ≥24/min
• heart rate ≥95/min
• SaO₂ <92% and/or a fall >3% from usual
• CRP ≥10 mg/L, if available.

Severe exacerbation includes similar clinical abnormalities accompanied, when ABG is obtained, by PaO₂ ≤60 mmHg and/or hypercapnia with acidosis (PaCO₂ >45 mmHg and pH <7.35).

Importantly, the report acknowledges that these thresholds still require further prospective validation.

How should an acute exacerbation be treated?

Bronchodilators

Initial bronchodilation should use:

SABA ± short-acting anticholinergic

A pMDI with or without spacer and nebulisation can both be effective. If nebulisation is required, air-driven rather than oxygen-driven nebulisation is preferred to reduce the risk of worsening hypercapnia.

Systemic corticosteroids

Recommended regimen:

Prednisone-equivalent 40 mg daily for 5 days.

Oral therapy is as effective as intravenous therapy in appropriate patients. Longer courses increase cumulative corticosteroid exposure without established additional benefit and may increase adverse outcomes.

Antibiotics

Antibiotics should be targeted rather than automatic.

GOLD supports treatment when there is evidence suggesting bacterial infection, including increased sputum purulence with other cardinal symptoms, a relevant previous positive sputum culture, or a requirement for invasive or non-invasive mechanical ventilation.

Antibiotic choice should reflect local resistance patterns. GOLD generally recommends 5–7 days, with ≤5 days for outpatient treatment.

Methylxanthines are not recommended because of their adverse-effect profile.

When is NIV required?

NIV is the preferred initial ventilatory mode for patients hospitalised with COPD exacerbations and acute respiratory failure when appropriate.

Randomised trials report success rates of approximately 80–85%. NIV improves oxygenation and respiratory acidosis, reduces respiratory rate and work of breathing, and importantly reduces intubation and mortality.

Invasive ventilation should be considered when NIV fails or when clinical circumstances require immediate invasive support.

What should happen after an exacerbation?

An exacerbation should trigger a reassessment of the entire COPD strategy rather than simply completion of steroids and antibiotics.

Maintenance long-acting bronchodilator therapy should be initiated or optimised as soon as possible. In patients with ≥1 moderate or severe exacerbation and elevated eosinophils, addition of ICS to dual bronchodilation should be considered at discharge.

Recovery is not always rapid. Symptoms may persist for weeks, and up to 20% of patients have not returned to their pre-exacerbation state at eight weeks.

Following hospitalisation, prognosis is particularly important: the report cites an approximately 50% five-year mortality, while 30-day readmission rates after hospitalised exacerbations are approximately 30–50%.

Pulmonary rehabilitation initiated during hospitalisation or within four weeks after discharge has been associated with reduced mortality in systematic review evidence.

How should patients be monitored in stable COPD?

Follow-up should assess more than spirometry.

At each review consider:

• symptoms and activity limitation
• exacerbation frequency and severity
• adherence
• inhaler technique
• treatment effectiveness and adverse effects
• smoking and ongoing exposures
• comorbidities.

GOLD suggests spirometry at regular intervals, for example annually, to identify rapid decline.

A major discordance between symptoms and airflow obstruction should prompt investigation for alternative explanations using additional physiology, exercise testing, CT or evaluation for comorbid disease.

If resting SpO₂ is ≤92%, GOLD recommends arterial blood gas measurement because pulse oximetry cannot reliably define PaO₂, PaCO₂ or pH.

Why do comorbidities deserve more attention?

GOLD 2026 has completely revised its multimorbidity chapter.

Cardiovascular disease, lung cancer, bronchiectasis, osteoporosis, anxiety and depression, metabolic disease, obstructive sleep apnoea and frailty are among the clinically important conditions accompanying COPD.

GOLD recommends actively searching for multimorbidity rather than regarding it as secondary to the lung disease. In general, COPD therapy should continue according to COPD principles while individual comorbidities are treated according to their usual standards.

The cardiovascular relationship is particularly important. The risk of myocardial infarction, arrhythmia, stroke and other cardiovascular events increases during an exacerbation and remains elevated after recovery.

Which treatments actually reduce mortality?

Not every treatment that improves symptoms has demonstrated a survival advantage.

Evidence cited by GOLD supports mortality reduction in appropriately selected populations with:

• smoking cessation
• pulmonary rehabilitation following hospitalisation
• LTOT for severe chronic resting hypoxaemia
• selected long-term NIV in hypercapnic respiratory failure
• lung volume reduction surgery in highly selected patients
• LABA + LAMA + ICS in selected symptomatic, exacerbation-prone patients.

For triple therapy, mortality evidence comes particularly from IMPACT and ETHOS and should not be generalised to every patient with COPD. These trials enrolled symptomatic patients enriched for frequent and/or severe exacerbations.

Clinical takeaway

The central message of GOLD 2026 is increasingly clear: COPD management should be driven by symptoms, exacerbation activity and treatable traits rather than FEV₁ alone.

The most immediately practice-changing development is the recognition that one moderate exacerbation is clinically important. A patient with even one moderate exacerbation in the previous year now enters Group E at initial assessment, and a moderate or severe exacerbation during follow-up should prompt reassessment and potential treatment escalation.

LABA + LAMA remains the pharmacological backbone for symptomatic or exacerbation-prone COPD. ICS should be targeted principally towards exacerbation prevention, with blood eosinophils helping estimate likely benefit. For a small, highly selected group with eosinophilic disease and persistent exacerbations despite triple therapy, biologics now provide another therapeutic option.

But optimal COPD care extends well beyond inhalers: smoking cessation, vaccination, pulmonary rehabilitation, correct inhaler technique, appropriate oxygen and ventilatory support, and active identification of multimorbidity remain fundamental.

Full reference

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: 2026 Report. Global Initiative for Chronic Obstructive Lung Disease; 2026. Version 1.3, 8 December 2025.

The report states that the updated 2026 report, Pocket Guide and supporting references are available through the GOLD website.