COPD detection refined with new diagnostic schema

Incorporating spirometry with respiratory symptoms and quality of life and structural lung abnormalities on CT imaging to meet criteria for a chronic obstructive pulmonary disease (COPD) diagnosis spots additional patients at risk of poor respiratory outcomes, according to the results of a study presented at the ATS annual meeting and simultaneously published in JAMA.

When the diagnostic schema was applied to the longitudinal Genetic Epidemiology of COPD (COPDGene) cohort, 15.4 percent of individuals without airflow obstruction were newly identified as having COPD. Conversely, 6.8 percent of those with airflow obstruction were reclassified as not having COPD. [JAMA 2025;doi:10.1001/jama.2025.7358]

Compared with individuals classified as not having COPD, reclassified individuals with a new COPD diagnosis were more likely to experience more exacerbations (adjusted incidence rate ratio, 2.09, 95 percent confidence interval [CI], 1.79–2.44; p<0.001) and more rapid FEV1 decline (adjusted β, −7.7 mL/y, 95 percent CI, −13.2 to −2.3; p=0.006), in addition to having greater risks of all-cause mortality (adjusted hazard ratio [aHR], 1.98, 95 percent CI, 1.67–2.35; p<0.001) and respiratory-specific mortality (aHR, 3.58, 95 percent CI, 1.56–8.20; p=0.003).

Among individuals with airflow obstruction on spirometry, those no longer classified as having COPD based on the new diagnostic schema had outcomes similar to those without airflow obstruction. These reclassified individuals had normal lung function and minimal symptoms, and only a few of them were taking long-acting inhaled controller therapies.

Results were replicated in the Canadian Cohort Obstructive Lung Disease (CanCOLD) cohort, wherein the application of the new diagnostic schema led to substantial reclassifications. Specifically, 7.0 percent of those without airflow obstruction were newly classified as having COPD, whereas 16.0 percent of those with airflow obstruction were reclassified as no longer having COPD.

The COPDGene cohort included 9,416 adults (mean age at enrolment 59.6 years, 53.5 percent men, 32.6 percent Black, 52.5 percent currently smoked). Of these individuals, 43.6 percent, 7.9 percent, 19.2 percent, 11.4 percent, and 5.7 percent had GOLD disease severity grades 0 through 4, respectively.

The CanCOLD cohort comprised 1,341 participants, of which 41.3 percent never smoked.

Diagnosing COPD

“It is increasingly recognized that 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,” according to the researchers who developed the schema. “Although spirometry continues to be a primary component in the diagnosis of COPD, the new schema allows a COPD diagnosis if spirometry is not available.”

The new diagnostic schema identifies COPD according to major and minor criteria. The major criterion is airflow obstruction, defined by a postbronchodilator FEV1/FVC ratio <0.7. For the minor criteria, two are imaging-based (emphysema and thickened airway walls based on visual analyses of chest CT scans) and three are symptom-based (dyspnea, respiratory quality of life scores, and chronic bronchitis).

“Individuals are classified as having COPD if they have the major criterion and at least one minor criterion (major diagnostic category) … When airflow obstruction is not present or spirometry is not available, individuals can be categorized as having COPD if at least three of the five minor criteria are met (minor diagnostic category),” the researchers pointed out.

To ensure accuracy and rule out other conditions, if a clinician attributes respiratory symptoms to other causes “as much as or more than” to COPD, at least two of the three minor criteria must be imaging-based, they added.

“Current spirometry-based guidelines for COPD require that patients have respiratory symptoms but do not specify how they should be quantified,” the researchers said.

In the COPDGene cohort, the new schema did not miss a single individual who would have been classified as having COPD according to the GOLD recommendations regardless of how minimal symptoms were defined. Furthermore, it resulted in a diagnosis of COPD for more women (169 of 4,723; 3.6 percent) and Black individuals (276 of 3,366 [8.2 percent]).

A milestone

In a linked editorial piece, Dr Francesca Polverino from the Baylor College of Medicine in Houston, Texas, US, described the new diagnostic schema as a milestone in redefining how COPD is diagnosed, “moving well beyond the traditional confines of airflow obstruction alone. [JAMA 2025;doi:10.1001/jama.2025.6653]

“What truly sets this reclassification apart is its groundbreaking assertion that airflow obstruction is no longer a requirement for a COPD diagnosis. Likewise, its presence alone does not automatically confirm the diagnosis. This shift acknowledges that many individuals have classic COPD-related pathology and symptoms without meeting the old spirometry thresholds,” Polverino said.

She emphasized that the implications of this reclassification, though seemingly subtle, are profound for health equity and how inclusively COPD is diagnosed.

“Historically, African American individuals have shown a higher prevalence of emphysema even in the absence of measurable airflow limitation on spirometry… By including symptom- and imaging-based criteria, not just airflow obstruction, the updated model may allow more individuals who identify as Black or African American to receive an accurate diagnosis, addressing a long-standing diagnostic blind spot,” she continued.

Then again, Polverino acknowledged a need to better understand which individuals within these reclassified groups will genuinely benefit from early treatment and what specific interventions would be most effective.