“Today, the management of hypertension and diabetes no longer relies on the presence of symptoms as a prerequisite for intervention. Could we adopt a similar approach to chronic obstructive pulmonary disease (COPD), using objective assessments and longitudinal monitoring to identify patients who truly require intervention before significant symptoms emerge?”
At the 2026 Annual Congress of the Chinese Thoracic Society (CTS 2026), Academician Zhong Nanshan from the First Affiliated Hospital of Guangzhou Medical University emphasized that some patients with mild-to-moderate COPD may have minor or no obvious symptoms while their disease continues to progress. Through longitudinal follow-up and multidimensional assessment, identifying patients who may benefit from early intervention could help more patients remain stable within GOLD lung function stages I and II over the long term.
At present, there remains debate over whether asymptomatic individuals should undergo screening and when treatment should be initiated. Academician Zhong argued that clinical attention should not be delayed until symptoms become obvious or the disease has already progressed to a more advanced stage. Some patients may already have functional or structural abnormalities despite minimal symptoms. Identifying these patients at an earlier stage may create an opportunity for timely intervention.
Clinical follow-up has shown that when patients progress from GOLD stage II to grade III, substantial changes may occur in acute exacerbations, quality of life, and exercise capacity. An analysis from the COMPASS cohort, which included 1,533 patients followed for approximately 2.5 years, showed that 87.6% of asymptomatic patients experienced clinically important deterioration (CID), with no significant difference across various symptom strata. Another analysis focusing on patients with mild-to-moderate disease found that decline in lung function was the predominant manifestation of disease instability, occurring more frequently than worsening symptom scores or acute exacerbations.
Academician Zhong emphasized that disease severity and disease activity are two distinct dimensions of assessment. Disease severity reflects the patient’s current clinical state, whereas disease activity reflects the trajectory of disease progression. Even among patients currently classified as GOLD stage I or II, persistent decline in lung function or other indicators suggesting ongoing disease activity should prompt further evaluation of the need for intervention.
To identify these patients, Academician Zhong proposed incorporating lung function, changes in symptoms or health status, and acute exacerbations into a comprehensive assessment, while also paying greater attention to annualized CID. Compared with a single assessment, longitudinal follow-up provides a more complete picture of disease evolution and may help clinicians identify patients who are more likely to progress.
An important question is whether early treatment can translate into meaningful clinical benefit once high-risk patients have been identified. Academician Zhong noted that the previous Tie-COPD study and post hoc analyses have provided evidence supporting early treatment in patients with mild-to-moderate COPD, with potential benefits across multiple domains, including lung function, acute exacerbations, and health status. In a post hoc analysis of patients with GOLD stage I COPD, treatment not only improved lung function but also reduced acute exacerbations and improved COPD Assessment Test (CAT) scores.
In addition, the PIONEER study showed that dual bronchodilator therapy with glycopyrronium/formoterol improved lung function in patients with mild-to-moderate COPD and reduced the risk of first CID by 41% compared with placebo. Follow-up findings also suggested that continued treatment may help maintain improvements in lung function.
Academician Zhong emphasized that COPD treatment should address not only current symptoms and the prevention of acute exacerbations, but also long-term disease progression, with the aim of slowing the decline in lung function and maintaining disease stability as long as possible. Previous studies have shown that some patients with more advanced disease can achieve sustained disease stability following treatment. Academician Zhong suggested moving this goal further upstream, so that appropriate intervention can be provided while patients are still in GOLD stages I and II, with the aim of reducing the likelihood of progression to more advanced stages.
Determining which patients with mild-to-moderate COPD may benefit from earlier treatment requires careful consideration of changes observed during longitudinal follow-up. Academician Zhong reported that a three-year follow-up of GOLD stages I and II patients in the ECOPD cohort found that approximately 26% experienced an annual decline in forced expiratory volume in one second (FEV?) of more than 60 mL. Even among patients with apparently similar mild-to-moderate disease, the rate of lung function decline can vary substantially. A single pulmonary function measurement or the patient’s current symptom burden may therefore be insufficient to capture the trajectory of disease progression.
Additional assessments, including cardiopulmonary exercise testing, impulse oscillometry, and chest computed tomography (CT), may provide further information. Relevant studies have shown that abnormalities in ventilatory efficiency, small-airway dysfunction, emphysema, and air trapping are associated with subsequent lung function decline or an increased risk of acute exacerbations. By integrating these findings with longitudinal clinical information, clinicians may obtain a more comprehensive understanding of disease progression and identify patients who may require earlier intervention.
For more patients to receive diagnosis and management at an earlier stage, community healthcare settings need adequate capacity for pulmonary function testing and longitudinal follow-up. Traditional pulmonary function testing requires standardized procedures and good patient cooperation. The team led by Academician Zhong is therefore exploring the use of portable devices, impulse oscillometry, augmented reality-assisted guidance, and artificial intelligence-assisted quality control and interpretation. These approaches may facilitate the implementation of pulmonary function assessment in primary-care settings while improving testing quality.
Academician Zhong proposed that individuals aged 40 years or older, even in the absence of obvious respiratory symptoms, should pay attention to early screening. For patients already diagnosed with GOLD stage or II COPD, the need for intervention should be determined through comprehensive assessment. Going forward, his team will further investigate which patients are most suitable for early treatment and explore more targeted therapeutic strategies based on individual phenotypes and endotypes. Through continuous follow-up and longitudinal disease management, the goal is to help more patients maintain long-term disease stability and preserve their ability to live and work normally.
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