review · European Respiratory Journal
Chronic obstructive pulmonary disease diagnosis relies on demonstrating airflow obstruction through forced spirometry, defined by a fixed ratio of forced expiratory volume in one second to forced vital capacity below 0.7. An evaluation of pre- and post-bronchodilator testing shows that while both methods yield concordant diagnostic outcomes in most instances, post-bronchodilator testing reduces diagnosed prevalence by up to 36 percent. Discrepancies emerge in specific patient groups. Volume responders exhibit disproportionate increases in vital capacity following bronchodilation, exposing airflow limitation that is concealed beforehand. Flow responders demonstrate greater airflow improvements that normalise ratios temporarily, although these patients face elevated risks of developing obstruction later and require longitudinal monitoring. Updated recommendations advise using pre-bronchodilator spirometry to rule out disease and reserving post-bronchodilator testing for diagnostic confirmation, reducing clinical workloads while preventing overdiagnosis.
Accurate diagnostic protocols are critical for managing chronic lung conditions effectively. Establishing a clear two-step pathway that uses initial testing to rule out disease and subsequent testing to confirm it prevents overdiagnosis, identifies subtle presentations caused by gas trapping, and reduces unnecessary burdens on healthcare services.
These recommendations are immediately applicable to healthcare providers, respiratory clinics, and diagnostic services. While not presenting a proprietary device, the guidance provides immediate operational utility for clinical workflows. Manufacturers of spirometry devices and clinical decision-support software can incorporate these diagnostic criteria into algorithmic reporting tools to automate the interpretation of pre- and post-bronchodilator results.
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The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report states that the diagnosis of COPD should be considered in individuals with chronic respiratory symptoms and/or exposure to risk factors. Forced spirometry demonstrating airflow obstruction after bronchodilation is required to confirm the diagnosis using a threshold of forced expiratory volume in 1 s (FEV<sub>1</sub>)/forced vital capacity (FVC) ratio <0.7. This GOLD Science Committee review weighs the evidence for using pre- or post-bronchodilator (BD) spirometry to diagnose COPD. Cohort studies have shown that pre- and post-BD spirometry give concordant diagnostic results in most cases, although the prevalence of COPD is up to 36% lower with post-BD values. Discordant results may occur in "volume" or "flow" responders. Volume responders have reduced FVC due to gas trapping causing FEV<sub>1</sub>/FVC ≥0.7 pre-BD, but a volume response occurs post-BD with a greater improvement in FVC relative to FEV<sub>1</sub> decreasing the ratio to <0.7. Flow responders show a greater FEV<sub>1</sub> improvement relative to FVC which may increase FEV<sub>1</sub>/FVC from <0.7 pre-BD to ≥0.7 post-BD; these individuals have an increased likelihood of developing post-BD obstruction during follow-up and require monitoring longitudinally. GOLD 2025 recommends using pre-BD spirometry to rule out COPD and post-BD measurements to confirm the diagnosis. This will reduce clinical workload. Post-BD results close to the threshold should be repeated to ensure a correct diagnosis is made. Post-BD measurements ensure that volume responders are not overlooked and limit COPD overdiagnosis.
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DOI: 10.1183/13993003.01603-2024
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