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EDITORIAL
Ca r d i o va s C u l a r ri s k i n COPD Pat i e n t s
Stable COPD patients often have increased cardiovascular disease
(CVD) prevalence due to aging, smoking, inflammation, hypoxemia,
and hyperinflation.8–10 CVD worsens COPD through edema,
postcapillary pulmonary hypertension (PH), and reduced oxygen
delivery. Screening for CVD in COPD patients is pivotal. During
COPD exacerbations, cardiovascular risk spikes due to inflammation
and gas exchange issues, with heightened risk of events such
as myocardial infarction. This risk remains high postdischarge,
especially in severe cases.11
aP P l i C at i o n o f Ch e s t Co m P u t e d
to m o g r a P h y
Chest computed tomography (CT) scans are increasingly used in
COPD evaluation, assessing emphysema severity, aiding surgical
decisions, and screening for lung cancer. They reveal bronchiectasis,
mucus plugs, and airway changes, helping identify small airway
abnormalities. CT also detects comorbidities such as coronary
calcification, pulmonary artery enlargement, bone density,
interstitial lung disease, hiatal hernias, and liver steatosis, affecting
mortality.12
Cl i m at e Change a n d COPD
Climate change intensifies extreme weather, affecting COPD
patients. Heatwaves increase mortality, while cold weather
exacerbates symptoms. Higher outdoor temperatures are linked
to hospitalizations13–15; lower ones cause exacerbations. Indoor
conditions, affected by economic factors, impact symptoms.
Studies show heat worsens dyspnea, and indoor heat increases
symptoms and short-acting β-agonists use.16 Weather influences
air quality; ozone forms in heat, and pollutants disperse with wind/
The 2025 Global Initiative for Chronic Obstructive Lung
Disease (GOLD) report, renewed annually, presents key
updates on the diagnosis, management, and prevention of
chronic obstructive pulmonary disease (COPD). Discussed at
the GOLD International COPD conference, the report includes
advancements in spirometry, cardiovascular risk management,
and the effects of climate change. It introduces new treatments
such as ensifentrine and dupilumab, updates vaccination
recommendations, and addresses the management of patients
on long-acting β-agonists and inhaled corticosteroids.
dys b i o s i s
Genetic sequencing of respiratory samples has revealed the
diverse microbiome of the lower respiratory tract, challenging
the notion of sterility. Dysbiosis, a disruption in this microbiome,
is linked to COPD and influenced by factors such as smoking
and preterm birth. These changes affect the gut–lung axis
through immune interactions.1 Dysbiosis is associated with
COPD exacerbations and lung inflammation.2 Viral infections,
antibiotics, and corticosteroids can further alter the microbiota.
Despite these findings, more research is needed to understand
causal relationships and explore prognostic, diagnostic, and
therapeutic potentials.
diagnosis a n d assessment
The GOLD guideline for diagnosing COPD still uses a
postbronchodilator forced expiratory volume in 1 second (FEV1)
to forced vital capacity (FVC) ratio <0.7, which may overdiagnose
in the elderly3,4 and underdiagnose young adults.5 Alternatives
such as lower limit of normal (LLN) and z-scores can provide
better management insights, especially in young adults. While
both methods can classify patients differently, their clinical
significance is uncertain.6,7 GOLD prefers the fixed ratio due to its
simplicity, advising retesting if the ratio is between 0.6 and 0.8.
The Global Lung Initiative’s new race-neutral global equations are
recommended despite some controversy. GOLD stages airflow
obstruction by predicted FEV1 percentage, while the European
Respiratory Society and American Thoracic Society suggest using
z-scores for more precise severity staging.
Spirometry Diagnosis Flowchart
If the pulmonary function test before using a bronchodilator
does not indicate obstruction, there is no need to perform
the test after bronchodilator administration unless there is
strong clinical suspicion of COPD. If the values before using the
bronchodilator indicate obstruction, the measurements after
bronchodilator administration should be used to confirm the
diagnosis of COPD.
1,3Department of Chest Medicine, Taichung Veterans General Hospital,
Taichung, Taiwan, Republic of China
2Department of Internal Medicine, China Medical University Hospital,
Taichung, Taiwan, Republic of China
Corresponding Author: Wei-Chang Huang, Department
of Chest Medicine, Taichung Veterans General Hospital,
Taichung, Taiwan, Republic of China, Phone: +886 4 23592525,
e-mail: huangweichangtw@gmail.com
How to cite this article: Tsao YC, Chen CH, Huang WC. What is New
about the 2025 GOLD Report? Indian J Respir Care 2025;https://doi.
org/10.5005/jp-journals-11010-1182.
Source of support: Nil
Conflict of interest: None
What is New about the 2025 GOLD Report?
Yi-Chun Tsao1, Chia-Hung Chen2, Wei-Chang Huang3
Indian Journal of Respiratory Care (2025): 10.5005/jp-journals-11010-1182
What is New about the 2025 GOLD Report?
Indian Journal of Respiratory Care, Volume 00 Issue 00 (xxxx 2025)
2
cells/μL serves as an indicator of increased risk of adverse outcomes
following ICS withdrawal (Figs 1 and 2).
COVID-19 a n d COPD
The COVID-19 pandemic required social distancing, leading
healthcare systems to adopt telemedicine, particularly for COPD.
Pulmonary rehabilitation and self-management are the most
studied areas. Evidence shows remote pulmonary rehabilitation
offers similar outcomes to hospital-based programs, providing an
alternative for stable chronic respiratory disease patients. However,
it still needs face-to-face assessments, trained personnel, and
infrastructure. A 2022 Cochrane study found self-management
improves quality of life and reduces hospitalizations.18 Despite
potential benefits, remote self-management faces unresolved issues
and limitations, with no studies showing additional advantages over
traditional methods.
COPD Combined w i t h Pu l m o n a r y
hyPertension
Pulmonary hypertension (PH) in COPD patients is characterized
by elevated mean pulmonary arterial pressure (mPAP) >20 mm
Hg as measured by right heart catheterization. PH is divided
into five groups based on pathophysiology and treatment: (1)
pulmonary arterial hypertension, (2) PH with left heart disease,
(3) PH with lung diseases/hypoxia, (4) chronic thromboembolic
PH, and (5) PH with unclear mechanisms. COPD patients often
present with mild PH, but severe PH, affecting about 5%, is
critical due to its impact on prognosis and requires individualized
treatment. Echocardiography and N-terminal pro-brain natriuretic
peptide are key ancillary diagnostic tools. Management involves
specialized PH centers, and severe cases may use off-label
phosphodiesterase 5 inhibitors, though efficacy varies.19,20 More
randomized controlled trials are needed in the future to further
explore the therapeutic effects of PH-targeted drugs on PH-COPD
patients.
rain. High temperatures and pollution affect COPD, especially in
winter. Proper inhaler use and disposal help mitigate environmental
impacts.
va CC i n at i o n
The vaccination recommendations for COPD patients have
been updated according to the Centers for Disease Control and
Prevention (CDC) guidelines in the GOLD 2025 document. Patients
should receive yearly influenza and pneumococcal vaccines (PCV20
or PCV21), severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) immunization, and tetanus toxoid and reduced diphtheria
toxoids/acellular pertussis vaccine (Tdap) if not vaccinated in
adolescence. Zoster and respiratory syncytial virus vaccines are
recommended for those over 50 and 60 years, respectively, or with
cardiopulmonary comorbidities.
ensifentrine, du P i lu m a b , a n d ICS
ma n a g e m e n t
The GOLD 2025 guidelines emphasize personalized treatment
for COPD patients. If initial therapy is effective, it should
be maintained. For those with persistent symptoms on
monotherapy, combining long-acting bronchodilators is
recommended, with ensifentrine as an option for addition if
symptoms persist. Ensifentrine, a novel phosphodiesterase 3
and 4 inhibitor with both anti-inflammatory and bronchodilatory
effects,17 improves lung function and dyspnea according to
the phase 3 ENHANCE trials. For patients on triple therapy
(long-acting β-agonists plus long-acting muscarinic antagonist
plus inhaled corticosteroid, LABA + LAMA + ICS) with ongoing
exacerbations, dupilumab may be added if the blood eosinophil
count (BEC) is ≥300 cells/μL and chronic bronchitis symptoms are
present. Dupilumab has shown significant benefits in reducing
exacerbations and improving lung function in two large, phase
III, double-blind, randomized trials. To handle patients currently
on LABA + ICS, an exacerbation indicates that switching to LABA
+ LAMA is an option if their BEC is below 100 cells/μL; however,
if their BEC is 100 cells/μL or higher, moving to triple therapy is
recommended.
For those without a history of exacerbations, we may consider
changing to LABA + LAMA. ICS withdrawal should be considered
carefully, especially in patients with severe pneumonia or high
tuberculosis risk, as it may increase the risk of infections. A BEC ≥300
Fig. 1: Follow-up pharmacological treatment for dyspnea; Source: Modified
from 2025 GOLD report; *Ensifentrine has official approval only from the
FDA
Fig. 2: Follow-up pharmacological treatment for
exacerbation; Source: Modified from 2025 GOLD report; †Dupilumab
may be considered if BEC ≥300 cells/μL and chronic bronchitis symptoms
are present
What is New about the 2025 GOLD Report?
Indian Journal of Respiratory Care, Volume 00 Issue 00 (xxxx 2025) 3
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