COPD screening

No symptoms: USPSTF says do not screen, and that includes current and former smokers. Its response to public comment: "Although smoking is the primary risk factor for COPD, the evidence reviewed, which included current and former smokers, did not show an overall benefit for screening for COPD in asymptomatic adults." GOLD agrees only for people with no significant exposure to tobacco or other risk factors. For a symptom-free smoker, the two bodies give different answers; see where they disagree, below.

No symptoms, but risk factors: smoking keeps you inside USPSTF's recommendation, as above. Two very-high-risk groups are outside it: "It does not apply to populations at very high risk for COPD, such as persons with α-1 antitrypsin deficiency or workers exposed to certain toxins at their job." USPSTF gives them no screening advice either way. GOLD advocates active case-finding in people with symptoms and/or specific COPD risk factors: a questionnaire first, then spirometry for those who answer positively. Its examples include unexplained shortness of breath, more than 20 pack-years of smoking, a history of recurrent chest infections, and early-life events. GOLD also recommends spirometry for targeted patients having low-dose CT for lung cancer screening, and when chest imaging shows incidental abnormalities consistent with airway disease, such as emphysema, air trapping, airway wall thickening or mucus plugging.

Symptoms: outside USPSTF's recommendation. In its words, "It does not apply to persons who present to clinicians with symptoms such as chronic cough, sputum production, difficulty breathing, or wheezing." That is a diagnostic visit, not screening. GOLD's list of reasons to consider COPD and perform spirometry (its Figure 2.1) is shortness of breath that is progressive over time, worse with exercise, or persistent; recurrent wheeze; chronic cough, which may come and go and may not bring up sputum; recurrent lower respiratory tract infections; or a history of risk factors, such as tobacco smoke, smoke from home cooking and heating fuels, and occupational dusts, vapors, fumes, gases and other chemicals. GOLD says chronic shortness of breath is the most characteristic symptom, that cough with sputum is present in up to 30% of patients, and that spirometry is required to make the diagnosis. If any of these describe you, tell your clinician.

Spirometry is used two ways, and the difference matters. As a diagnostic test it is done after a bronchodilator. USPSTF: "A postbronchodilator spirometry ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) of less than 0.70 confirms the presence of persistent airway obstruction and a diagnosis of COPD in persons with appropriate symptoms and significant exposures to noxious stimuli." GOLD likewise requires a post-bronchodilator FEV1/FVC below 0.7 to make the diagnosis, and says pre-bronchodilator spirometry can be used to rule COPD out.

As a screening or case-finding step, both bodies describe questionnaires. USPSTF reports that "Externally validated questionnaires have good sensitivity but fair specificity for detecting COPD in primary care populations", with sensitivity from 67% to 90% and specificity from 25% to 73%, so a questionnaire flags many people who do not have COPD. GOLD's case-finding pathway (its Figure 2.9, adapted from a 2024 paper by Aaron and colleagues) runs in steps:

• people at risk complete a case-finding questionnaire, such as the LFQ, CDQ, COPD-PS, PUMA or CAPTURE;
• a positive questionnaire leads to a hand-held device test in primary care (PEF, COPD-6 or PIKO-6) or to confirmatory pre-bronchodilator spirometry in specialty care;
• a positive result leads to a full assessment, including post-bronchodilator spirometry;
• a negative result leads to monitoring symptoms and addressing risk factors.

The figure lists age 35 or older among the features of people at risk, alongside exposure to tobacco smoke, household and outdoor air pollution or occupational exposures, genetic factors, prematurity and early-life disadvantage, and respiratory symptoms. GOLD gives no interval for repeating any of these steps.

For a person without symptoms, a positive questionnaire or a low reading leads to diagnostic testing, and USPSTF found that what follows does not help people who feel well. It found "inadequate evidence that treatment of asymptomatic COPD reduces morbidity or mortality or improves health-related quality of life", and noted that "large observational studies in screen-relevant populations suggest possible harms for LAMA or LABA initiation or use of ICS" (long-acting inhaled bronchodilators and inhaled corticosteroids, which are COPD treatments). It counts clinic time as a cost too: "In addition to potential treatment harms, there are opportunity costs to screening that may include time spent on counseling and providing services and patient referrals for diagnostic testing."

A test result does not reliably get people to quit either: "Studies have not consistently shown that receipt of spirometry results or information about “lung age” increases smoking cessation." What USPSTF recommends instead is direct: "Current smokers (regardless of whether COPD is diagnosed) should receive smoking cessation counseling and be offered behavioral and pharmacologic therapies to stop smoking."

For a person with symptoms, a post-bronchodilator FEV1/FVC below 0.7 confirms COPD on both bodies' terms, and in GOLD's pathway leads to a full assessment. A negative result in GOLD's case-finding pathway is not the end of it: GOLD sends that person to monitoring of symptoms and work on risk factors.