GOLD 2025 requires a post-bronchodilator FEV₁/FVC ratio of less than 0.70 to confirm a diagnosis of COPD.¹ However, a newly proposed diagnostic framework that incorporates symptoms, quality of life measures, spirometry, and CT imaging can identify additional cases of COPD additional individuals with COPD who are at higher risks of death, more frequent exacerbations, and faster lung function decline.²

This study, published in JAMA, utilized data from two longitudinal cohorts: 10,305 participants (mean age ~60 years; 53.5% men; 52.5% current smokers) in the Genetic Epidemiology of COPD (COPDGene) and 1561 participants from the Canadian Cohort Obstructive Lung Disease (CanCOLD). The aim of this study was to evaluate if adopting a multidimensional diagnostic approach, which integrated respiratory symptoms and CT imaging abnormalities with the traditional diagnostic criteria, could identify additional cases of COPD.

The new proposed COPD diagnostic schema included the major criterion of airflow obstruction, indicated by a postbronchodilator FEV₁/FVC ratio <0.70. Additionally, it requires the presence of at least one of five minor criteria (emphysema or bronchial wall thickening on CT, dyspnea, poor respiratory quality of life, or chronic bronchitis). Or, in individuals whose respiratory symptoms may be attributable to other causes, at least three of the five minor criteria, which must mandatorily include both emphysema and bronchial wall thickening on CT must be present. The outcome measures were all-cause mortality, respiratory cause-specific mortality, exacerbations, and annualized change in FEV1.

Among 5250 patients without airflow obstruction in the COPDGene cohort, 811 were reclassified as per the new diagnostic schema as having COPD by minor diagnostic category. Whereas, out of the 4166 participants with airflow obstruction, 282 patients were found to not have COPD under the new classification system.

Compared to participants classified as not having COPD under the new system, those newly diagnosed with COPD under the revised schema had significantly worse outcomes with higher all-cause mortality (adjusted hazard ratio [aHR] 1.98), respiratory-specific mortality (aHR 3.58), greater exacerbation rates (adjusted incidence rate ratio 2.09), and a more rapid decline in FEV₁ (adjusted β = –7.7 mL/year). Among participants with airflow obstruction on spirometry, those reclassified as not having COPD under the new diagnostic schema, had clinical outcomes comparable to those without airflow obstruction.

In the CanCOLD cohort of 1341 adults, individuals who were identified as having COPD, as per the new criteria,  experienced a two-fold increased risk for more frequent exacerbations with an adjusted incidence rate ratio of 2.09.

This study demonstrates the feasibility of a new multidimensional diagnostic framework for COPD that integrates symptoms and imaging findings alongside traditional spirometry. Implementation of this approach helps identify previously undiagnosed cases of COPD and individuals at high risk for adverse outcomes. “Spirometry does not capture all aspects of this complex heterogeneous disease, and there is growing consensus in the respiratory community that a COPD diagnosis should not be based on spirometry alone,” write the authors.

References

1.   Global Initiative for chronic obstructive lung disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2025 Report. Available at: https://goldcopd.org/2025-gold-report/. Accessed on May 27, 2025.

2.   COPDGene 2025 Diagnosis Working Group and CanCOLD Investigators; Bhatt SP, et al. A multidimensional diagnostic approach for chronic obstructive pulmonary disease. JAMA. 2025 May 18:e257358. doi: 10.1001/jama.2025.7358.