GOLD Science Committee recommendations for the use of pre- and post-bronchodilator spirometry for the diagnosis of COPD

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 (FEV₁)/forced vital capacity (FVC) ratio <0.7. This GOLD Science Committee review weighs the evidence for using pre- or postbronchodilator (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 FEV₁/FVC ≥0.7 pre-BD, but a volume response occurs post-BD with a greater improvement in FVC relative to FEV₁ decreasing the ratio to <0.7. Flow responders show a greater FEV₁ improvement relative to FVC which may increase FEV₁/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.