Editorial 

Beyond Obstruction—A Milestone in COPD Diagnosis

Francesca Polverino

JAMA 2025;333;(24):2151-2153

doi:10.1001/jama.2025.6653

The landscape of chronic obstructive pulmonary disease (COPD) is changing rapidly. Thanks to long-term studies tracking lung function and the integration of advanced imaging and analytic tools, we now have a much deeper understanding of how COPD presents in different patients. The emergence of multiomic technologies has further allowed researchers to uncover distinct biological subtypes—or etiotypes—of the disease.¹

Despite these advancements, COPD classification has remained overly dependent on airflow limitation as the main diagnostic criterion. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations, although foundational in clinical practice, have traditionally focused on spirometry-based obstruction, offering a limited view of a complex condition. Whereas recent updates have incorporated symptoms and imaging,² the approach is not integrated to detect and characterize all individuals affected by the diverse conditions that represent COPD. As multidimensional assessment tools evolve, it is clear that a more personalized and comprehensive diagnostic framework is overdue. The era of one-size-fits-all COPD care must give way to a more nuanced, patient-centered approach.

In this issue of JAMA, Bhatt et al³ mark a milestone in redefining how we diagnose COPD, moving well beyond the traditional confines of airflow obstruction alone. Using 2 robust, longitudinally tracked cohorts, COPDGene⁴and CanCOLD,⁵ the researchers propose a fresh, multidimensional framework for COPD classification. This new model introduces a combination of major and minor criteria to provide a more holistic view of the disease.

In this system proposed by Bhatt and colleagues, the major criterion for COPD remains familiar: the presence of airflow obstruction, specifically defined by a reduced postbronchodilator forced expiratory volume in the first second of expiration to forced vital capacity ratio on spirometry. However, what makes this model significantly more inclusive and reflective of clinical COPD diversity are the minor criteria, which are split between imaging and symptom-based factors. The imaging components include visual signs of emphysema and airway wall thickening via chest computed tomographic (CT) scans. Meanwhile, the symptom-based criteria consider dyspnea, reduced quality of life, and the presence of chronic bronchitis. To qualify for a COPD diagnosis under this new framework, a patient must meet either 1 major and at least 1 minor criterion (the major category) or, in the absence of airflow obstruction or if spirometry is not available, at least 3 of the 5 minor criteria (the minor category).

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.^6,7 In cases in which patients present with comorbidities that could plausibly explain symptoms better than COPD itself, the model suggests that at least 2 of the 3 minor criteria should be imaging based to support a COPD diagnosis.

This refined diagnostic model brings much-needed nuance to the conundrum and complexity of COPD diagnosis. It empowers clinicians to recognize and address COPD even at its earliest stages in diverse clinical contexts, especially among individuals who previously were not clearly classified under existing guideline-based criteria.

Beyond the more obvious clinical implications, this reclassification of COPD carries several subtle but profoundly important consequences, especially when it comes to health equity and diagnostic inclusivity.

First, one of the most notable shifts is how the new criteria affect the diagnosis of COPD among Black or African American populations. Historically, African American individuals have shown a higher prevalence of emphysema even in the absence of measurable airflow limitation on spirometry.⁸ Because traditional diagnostic methods hinge so heavily on spirometry values, many African American patients, despite having structural lung disease, have been undiagnosed or misdiagnosed. This gap is not just a minor technicality; it represents a major public health oversight that has been reinforced for decades. CARDIA researchers observed that when race-neutral reference equations were used to interpret lung function of individuals with normal spirometry values, the disparity in emphysema prevalence between African American and White individuals significantly narrowed. This finding suggests that conventional race-adjusted lung function equations may have systematically underestimated respiratory impairment in African American patients, meaning a significant number of them may have had underdiagnosed or undiagnosed genuine respiratory disease because of outdated spirometric thresholds.

Structural lung disease, such as emphysema, is still present and meaningful in these individuals, but traditional diagnostic tools fail to detect it. 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.

Second, this new reclassification challenges the clinical value of previously established categories such as GOLD stage 0, preserved ratio impaired spirometry,⁹ early COPD, or pre-COPD. These categories were originally introduced to flag individuals who do not meet the formal spirometric thresholds for COPD but may still be at risk of developing the disease and who, in some cases, might benefit from early intervention. However, under the newly proposed framework, a good proportion of individuals previously classified as having preserved ratio impaired spirometry or GOLD stage 0 actually fulfill the updated diagnostic criteria for COPD, which means they may no longer be considered merely at risk but instead as already having COPD and potentially in need of interventions, starting with lifestyle changes.

This reevaluation has potential clinical and therapeutic consequences and highlights a critical gap in current research: we still need a better understanding of which individuals within these reclassified groups will genuinely benefit from early treatment¹⁰ and what specific interventions would be most effective. As such, the reevaluation underscores the urgent need for targeted studies focused on these reclassified populations now designated as having COPD to refine treatment guidelines, ensure patients are neither overtreated nor undertreated under the new model, and determine whether it is safe to observe those individuals with baseline airflow obstruction who are no longer classified as having COPD.

One key area needing refinement is the role of imaging in COPD diagnosis. Although imaging criteria such as emphysema and airway wall thickening have been included, there is still a lack of standardized, precise imaging parameters that can guide clinical decisions effectively. Currently, quantitative CT analyses, which offer more objective and reproducible data, are available in only a handful of specialized laboratories and radiology departments.^11,12 These imaging modalities are far from routine clinical practice. To address the absence of widely applicable quantitative thresholds, Bhatt and colleagues took a practical and commendable approach by incorporating visual CT criteria, making the diagnostic process more feasible and immediately usable in routine care. Nonetheless, to fully integrate imaging into COPD diagnosis, the medical community must work toward scaling up access to advanced imaging analyses. Developing tools and protocols that make quantitative CT imaging feasible and affordable for widespread use would be a major step forward and would help establish clear thresholds and standards for what constitutes imaging-based evidence of COPD, making diagnoses more consistent and reliable across health care settings.

In developing this new model, another important area for further exploration is the limited inclusion of individuals who do not smoke. The COPDGene cohort focused exclusively on individuals who smoke, but those who do not were excluded from its analysis. Although approximately half of the participants in the CanCOLD study never smoked, the overall framework still leans heavily on data derived from COPD for individuals with a significant tobacco smoking history, leaving an important, at-risk population in a diagnostic gray zone. As our understanding of COPD evolves, especially with growing recognition that factors such as air pollution, occupational exposures, biomass smoke, and early-life events can also lead to COPD,^1,13 it becomes increasingly important to test how well this classification applies to individuals without a significant tobacco smoking history. The genetic architecture of COPD susceptibility in general populations, inclusive of individuals who never smoked, formed the basis for the development of polygenic scores that could complement a future diagnostic schema for the cost-effective detection of COPD both related and unrelated to prior tobacco smoke exposure.¹⁴ Exploring this susceptibility in future studies could lead to an even more inclusive framework that captures the full spectrum of COPD pathogenesis regardless of smoking history.

Last, the reclassification under this new framework underscores a significant knowledge gap: the absence of reliable biomarkers that can guide clinical decision-making and enhance the precision of COPD patient classification.

This study marks a pivotal point in the understanding and management of COPD. By introducing a broader, multicriteria framework, it moves the field beyond traditional diagnostic limitations and sets the stage for more individualized and inclusive COPD patient care. It not only challenges conventional thinking but also redefines the clinical conversation around COPD, encouraging a shift toward a more dynamic and responsive model of care. Rather than applying a uniform standard, this approach recognizes the complexity of the disease and advocates strategies that reflect its varied presentations across diverse populations, which is a win for everyone.

And perhaps it raises an even deeper question: if airflow obstruction is no longer essential for diagnosis, should we still be calling it COPD?