Shifting From Late Rescue to Early COPD Detection and Care

Better diagnosis, assessment, and management of patients with chronic obstructive pulmonary disease (COPD) care requires shifting from late rescue to prevention, experts said during a session at the 2026 GOLD International COPD Conference in Philadelphia, Pennsylvania.

The session, chaired by Claus Vogelmeier, MD, chair of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee and a professor of medicine at Philipps University of Marburg in Germany, and Àlvar Agustí, MD, PhD, professor of medicine at the University of Barcelona, built the argument that too many patients are diagnosed late and those who are found early benefit measurably.

COPD's “Black Hole” Diagnostic Gap

Agustí, who chairs the GOLD board of directors, called the diagnostic gap a “big, big black hole.” Roughly 70% of people with COPD worldwide are underdiagnosed and are receiving no treatment,¹ and the mean age at diagnosis is 65 to 70 years, which is far too late for a disease that may have progressed for decades, he said.

There are 3 main drivers of underdiagnosis:

• Patient factors, such as patients being unaware of symptoms or hesitant to go to the doctor, knowing they will be told to stop smoking.
• Health system factors, such as spirometry being unavailable or underused. Agustí noted that in his country every primary care physician has access to it, but they rarely use it.
• Provider-related factors, such as a poor understanding of the diagnostic criteria or inadequate training on how to use and interpret spirometry.

Agustí pointed to artificial intelligence (AI) as a possible fix to improve the diagnosis and management of COPD. A GOLD Science Committee perspective he led outlines how AI could flag undiagnosed patients in electronic health records, surface missed comorbidities, and prompt guideline-concordant care.² In his view, AI should alert physicians to what they are missing rather than wait to be asked.

“No correct diagnosis because underdiagnosis or misdiagnosis or delayed diagnosis results in no treatment or no correct treatment, and that results in worse outcomes,” Agustí concluded.

Finding Patients Who Are Already Suffering

Even when COPD is undiagnosed, the disease is far from silent, said Shawn Aaron, MD, senior scientist in inflammation and chronic disease at Ottawa Hospital Research Institute and professor of the Division of Respirology at the University of Ottawa.

Adults with undiagnosed COPD or asthma in a Canadian case-finding study reported worse quality of life, greater health care resource utilization, and poorer work productivity than healthy controls.³ Detection also comes late: In one Canadian province, 42% of new COPD diagnoses were made during an inpatient exacerbation, Aaron said, in line with British Columbia data showing that more than 40% of patients were diagnosed after a hospital admission.⁴

“In other words, the patient wasn't identified as having COPD until they were admitted to hospital with an exacerbation,” Aaron said. “That is way too late to make a diagnosis of a chronic disease.”

His answer was not population screening, which he called low yield and expensive and which the US Preventive Services Task Force recommends against in asymptomatic adults.⁵ Instead, he urged case finding in higher-risk groups. In active case finding, clinicians or researchers contact people in the community, ask about symptoms, and send those who screen positive for spirometry. In opportunistic case finding, patients are caught when they enter the system for another reason, such as lung cancer screening.

AI could extend that reach, Aaron said. On low-dose CT scans from the National Lung Screening Trial, a 1% quantitative emphysema threshold identified airflow obstruction with a sensitivity of about 65% in women and 74% in men aged 65 years and older.⁶ Never-smokers, who account for roughly 22% to 51% of COPD cases in published studies, can be flagged when a thoracic CT shows airway thickening, emphysema, or air trapping.⁷

Aaron then presented evidence that early detection changes outcomes. In a Canadian randomized trial, 508 adults with newly found, previously undiagnosed asthma or COPD received either guideline-based care from a pulmonologist and an asthma-COPD educator or usual primary care.⁸ He noted that finding the disease early and treating it according to guidelines with smoking cessation, vaccinations, medications, and counseling led to a 52% decrease in health care utilization for respiratory events over the following year compared with the usual care group. There was also an improved quality of life over the 1 year. Both groups improved and benefitted from the early diagnosis, Aaron noted, but those receiving guideline-concordant care improved more.

“Our current paradigm is treating the 75-year-old who's…finally come to medical attention because they can't walk to the bathroom anymore,” he said. “We have to find these people when they're short of breath, when they're walking uphill on the golf course, when they're 55 [years old]. Because if we find them then, we will improve their outcomes.”

References

1. Diab N, Gershon AS, Sin DD, et al. Underdiagnosis and overdiagnosis of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2018;198(9):1130-1139. doi:10.1164/rccm.201804-0621CI
2. Agustí A, Vila M, Faner R, et al. How artificial intelligence could improve the diagnosis and management of chronic obstructive pulmonary disease: a perspective from GOLD. Am J Respir Crit Care Med. 2026;212(11):2736-2744. doi:10.1093/ajrccm/aamag337
3. Gerstein E, Bierbrier J, Whitmore GA, et al. Impact of undiagnosed chronic obstructive pulmonary disease and asthma on symptoms, quality of life, healthcare use, and work productivity. Am J Respir Crit Care Med. 2023;208(12):1271-1282. doi:10.1164/rccm.202307-1264OC
4. Khakban A, Sin DD, FitzGerald JM, et al. Ten-year trends in direct costs of COPD: a population-based study. Chest. 2015;148(3):640-646. doi:10.1378/chest.15-0721
5. US Preventive Services Task Force; Mangione CM, Barry MJ, Nicholson WK, et al. Screening for chronic obstructive pulmonary disease: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2022;327(18):1806-1811. doi:10.1001/jama.2022.5692
6. Labaki WW, Xia M, Murray S, et al. Quantitative emphysema on low-dose CT imaging of the chest and risk of lung cancer and airflow obstruction: an analysis of the National Lung Screening Trial. Chest. 2021;159(5):1812-1820. doi:10.1016/j.chest.2020.12.004
7. Yang IA, Jenkins CR, Salvi SS. Chronic obstructive pulmonary disease in never-smokers: risk factors, pathogenesis, and implications for prevention and treatment. Lancet Respir Med. 2022;10(5):497-511. doi:10.1016/S2213-2600(21)00506-3
8. Aaron SD, Vandemheen KL, Whitmore GA, et al. Early diagnosis and treatment of COPD and asthma: a randomized, controlled trial. N Engl J Med. 2024;390(22):2061-2073. doi:10.1056/NEJMoa2401389