David M. G. Halpin

Background: Integrated COPD management has improved outcomes for patients with diagnosed COPD. The CONQUEST Quality Improvement Program aims to improve the diagnosis and management for patients with potential and diagnosed modifiable high-risk (MHR) COPD, defined as those with a history of exacerbations and opportunities for treatment optimization. Methods: Utilizing the CONQUEST registry and Optimum Patient Care (OPC) Research Database, this observational cohort analysis assessed changes in quality indicator attainment over 12 months among potentially undiagnosed, newly diagnosed and already diagnosed patients with MHR COPD in exposed and matched usual care (UC) general practices. In exposed practices, newly diagnosed and already diagnosed patients were restricted to those receiving OPC-led CONQUEST clinics. Outcomes were compared using difference-in-difference generalized linear models with overlap propensity weighting. Findings: From 168 UK practices, we identified 113,574 potentially undiagnosed (59,706 exposed, 53,868 UC), 2787 newly diagnosed (1448 exposed of which 252 attended OPC clinics, 1339 UC) and 38,054 already diagnosed (21,670 exposed of which 392 attended OPC clinics, 16,384 UC). Potentially undiagnosed patients in exposed practices were more likely to subsequently receive a spirometry-confirmed COPD diagnosis (1.0% vs 0.6%; adjusted ratios-of-risk-ratios [ARRR]:1.55, 95% CI: 1.19– 2.01) compared to UC. Initiation or step-up to guideline-appropriate inhaled therapy was more likely among OPC-supported patients in exposed practices for newly diagnosed (96.4% vs 55.7%; ARRR: 1.71, 95% CI: 1.41– 2.06) and already diagnosed (91.6% vs 39.8%; ARRR: 1.94, 95% CI: 1.77– 2.1212) versus unsupported UC. Interpretation: CONQUEST is associated with measurable improvements in quality indicator attainment aligned with guideline-recommended identification and management of COPD, including higher rates of spirometry-confirmed COPD diagnosis and treatment optimization. Future randomized trials will evaluate if this translates into improved outcomes including reduced exacerbations and hospitalizations.

Large-scale quality improvement programmes (QIPs) have diverse factors that may influence their success and can undergo rapid changes throughout their lifecycle. The COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST) programme has recently been implemented in primary care practices in the UK. The CONQUEST programme aims to identify patients with already diagnosed and undiagnosed COPD at high risk of COPD-related adverse outcomes and optimize their management. CONQUEST has been successful in identifying COPD patients who may represent an outsized opportunity to improve patient outcomes and healthcare utilization, whilst focusing on relatively few patients per primary care practice. This paper reviews the steps involved in implementing CONQUEST in the UK, focussing on the challenges encountered, the solutions used to overcome these challenges barriers, and the lessons learned for the implementation of QIPs more widely. Key lessons from this process include that QIPs need to be designed with the flexibility to adapt to multiple and different local contexts, that early monitoring of data across the lifecycle of a QIP allows efficient detection of issues and troubleshooting, and that planning for allocation of limited resources to a QIP is essential for real-world implementation. The problems and solutions described here are applicable to QIPs in a wide variety of high-risk diseases and different healthcare settings.

Extract Reply to P. Burney and co-workers: A single lung function measure does not capture COPD severity, it is necessary to demonstrate airflow obstruction to confirm diagnosis, and wider access to spirometry is needed. When appropriate the fixed ratio should be used to confirm a COPD diagnosis. https://bit.ly/4xGsrXW

Extract The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has published yearly recommendations for the diagnosis and management of patients with COPD since 2001 [1]. The 2026 GOLD update includes a number of new recommendations on the use of biologic treatments, multimorbidity and exacerbations; a more proactive strategy on screening and case finding; and discussions of the concepts of disease activity, disease stability and clinical control, and the potential role of artificial intelligence in the diagnosis and management of COPD [2]. Shareable abstract The 2026 GOLD document proposes a number of changes for the stratification of patients that are often misinterpreted. This editorial seeks to clarify this. https://bit.ly/48Qiyw2

Background: We explored the efficacy of AS01 _E -adjuvanted respiratory syncytial virus prefusion F protein-based vaccine (adjuvanted RSVPreF3) in subpopulations of participants with underlying medical conditions in the multi-country, phase 3 AReSVi-006 trial (conducted May/2021-May/2024). Methods: Medically stable ≥60-year-olds were 1:1-randomised to receive one adjuvanted RSVPreF3 or placebo dose pre-RSV season 1. In exploratory post-hoc analyses in subgroups of participants with underlying conditions (including COPD, asthma, diabetes, obesity [BMI≥30 kg·m ⁻² ]), we evaluated efficacy of one vaccine dose against RSV-related lower respiratory tract disease (RSV-LRTD), acute respiratory illness (RSV-ARI), and RSV-ARI-related complications ( e.g. , pneumonia, COPD/asthma exacerbation, cardiovascular events). We also evaluated (post-hoc) RSV-ARI-related systemic corticosteroid and antibiotics use in participants with COPD or asthma. Results: The efficacy analyses comprised 12 468 vaccine and 12 498 placebo recipients. Efficacy against RSV-LRTD over three RSV seasons was similar among participants with COPD (75.1%, 95% CI: 40.2–91.4), asthma (65.8%, 31.0–84.7), diabetes (69.8%, 37.5–87.1), and obesity (74.1%, 56.4–85.5) as in the overall study population (62.9%, 97.5% CI: 46.7–74.8). Efficacy was also observed against RSV-ARI in these subgroups. Efficacy against RSV-ARI-related complications was 74.4% (95% CI: 11.2–95.2) in participants with COPD and 60.8% (−9.9–88.7) in those with asthma. Among participants with COPD, 15.4% (1.9–45.4) of RSV-ARI episodes in vaccine versus 22.4% (12.5–35.3) in placebo recipients were treated with systemic corticosteroids, and 46.2% (19.2–74.9) versus 56.9% (43.2–69.8) with antibiotics. Conclusions: Post-hoc analyses of the AReSVi-006 trial suggest that adjuvanted RSVPreF3 may help prevent RSV-ARI, RSV-LRTD, and RSV-related complications in medically stable older adults with underlying medical conditions like COPD and asthma.

Rationale: Disease stability in COPD is a low disease activity state proposed as a treatment target. Objectives: Characterize COPD stability as a composite endpoint. Methods: Post hoc analyses were carried out on IMPACT and FULFIL (fluticasone furoate/umeclidinium/vilanterol [FF/UMEC/VI] vs dual therapies) and MATINEE/METREX/METREO (mepolizumab added onto triple therapy). Stability was defined as “no moderate/severe exacerbations and no worsening from baseline in CAT and FEV1”. We assessed whether achieving stability at Week 28 was prognostic of subsequent outcomes (time to first on-treatment moderate/severe exacerbation and time to all-cause mortality [ACM]) after Week 28 (IMPACT). Bayesian joint modeling evaluated the probability of achieving stability (IMPACT). Measurements and Main Results: Stability was achieved with FF/UMEC/VI by 22% of patients in IMPACT (Week 52) and by 46% of patients in FULFIL (Week 24); stability was achieved with mepolizumab +triple therapy by 18% of patients in MATINEE/METREX/METREO (Week 52). Patients were more likely to achieve stability with triple versus dual therapy and with mepolizumab versus placebo. Many individuals achieving stability had clinically meaningful improvements in CAT and FEV1. Patients achieving stability at Week 28 (vs patients who were not stable) had a 45.7% reduction in the risk of moderate/severe exacerbations and a 51.7% reduction in the risk of ACM after Week 28. Bayesian joint modeling demonstrated a mean (SD) posterior probability of stability: 25.60% (0.66) at Week 52 (FF/UMEC/VI). Conclusions: Our data provide further evidence for disease stability as an achievable COPD treatment target that predicts long-term clinical benefits in exacerbations and mortality.

Background: Type 2 (T2) inflammation is increasingly recognized in chronic obstructive pulmonary disease (COPD), though its immunopathological profile may differ from asthma. T2 inflammatory diseases often coexist, but their prevalence in COPD patients without asthma remains underexplored. Objective: This study investigated the prevalence of T2 inflammatory multimorbidities in individuals with COPD (without asthma) and compared it with those in people with asthma. It also examined the relationship between these multimorbidities and blood eosinophil counts (BEC). Methods: Using data from the Optimum Patient Care Research Database (OPCRD), we identified patients with COPD or asthma and assessed lifetime and adjusted prevalence of T2 comorbidities including allergic rhinitis, atopic dermatitis/eczema, nasal polyps, chronic rhinitis with or without polyps, eosinophilic oesophagitis, and ulcerative colitis. Prevalence was stratified by BEC and adjusted for demographic and clinical variables. Results: Among 122 509 COPD and 1 154 094 asthma patients, T2 multimorbidities were present in both groups but significantly less common in COPD. Allergic rhinitis and nasal polyps were notably less prevalent in COPD, even at higher BEC levels. Prevalence of multimorbidities increased with BEC in both groups, with stronger associations observed for nasal polyps and UC. Eosinophilic oesophagitis was rare across both cohorts. Conclusion: T2 multimorbidities are present in COPD and their prevalence increases with BEC, though they are generally less prevalent than in asthma, suggesting distinct immunopathological.

Background: Despite the established use of long-term oxygen therapy (LTOT) for chronic respiratory diseases, a simple tool to assess LTOT use, clinical effectiveness and side effects is not currently available. We therefore designed and developed the Questionnaire for Oxygen Therapy Evaluation (QuOTE). Methods: Delphi methodology was used by a group of international respiratory specialists to identify the domains and questions to include in the questionnaire. The questionnaire was beta-tested by a group of patients using LTOT. Results: In the first round, 13 clinical and academic respiratory clinicians agreed the domains to be included. Questions covered physical activity, dyspnoea, sleep quality, mental clarity, LTOT side effects, use patterns and equipment. Advantages and disadvantages of current tools, clinical assessment priorities for patients and clinicians and the caveats and advantages around length were discussed, further supported by the results of a confirmatory systematic literature review. 3 rounds of Delphi consensus method focused 18 questions to 9 questions. Usability tests for all but 3 patients reported the questionnaire was easy to understand, only 2 felt it was not quick and easy to complete and only 1 patient needed assistance to complete the 9 question QuOTE.

COPD is one of the leading causes of morbidity and mortality worldwide [1]. Spirometry provides an objective measure of airflow obstruction that, in the appropriate clinical context, confirms the diagnosis of COPD. However, globally, access to spirometry is limited, the test is under-utilised, and many people are either misdiagnosed [2] or under-diagnosed [3, 4]. The intrathoracic airway obstruction that characterises COPD can be detected by finding expiratory flow limitation on spirometry. A reduced forced expiratory volume in 1 s (FEV₁) to forced vital capacity (FVC) ratio demonstrates flow limitation, but for more than 30 years there has been an unproductive debate about which threshold should be used to define airflow limitation and identify airway obstruction in patients with suspected COPD. In this viewpoint article, we focus on the use of spirometry use in routine clinical practice to confirm or exclude a diagnosis of COPD, and aim to propose a way forward to end the debate.