Is it time to use pre-bronchodilator spirometry to rule out COPD?

The increasing social and economic burden of COPD forces us to find new approaches to facilitating timely diagnosis and intervention. Spirometry with evidence of a persistent airflow obstruction after bronchodilator (BD) testing represents a key element for the diagnosis [1]; BD testing, however, is time-consuming and sometimes complicated to perform, potentially leading to a suboptimal uptake in clinical practice. We read with interest the report by Singh et al. [2], in which the authors propose to decouple post-BD from pre-BD spirometry, with the recommendation to use the pre-BD spirometry to rule out COPD and the post-BD test to confirm the diagnosis. This approach may save time and increase the number of pre-BD spirometry tests, facilitating the identification and referral of individuals with symptoms and/or exposure and forced expiratory volume in 1 s (FEV₁) to forced vital capacity (FVC) ratio <0.7. Indeed, according to COPD Gene results, pre-BD spirometry is highly sensitive, with only 3% false-negatives, and these mainly represented by “volume responders”, whose obstruction becomes evident only after bronchodilation.