A Proposed Consensus Definition of Severe COPD: a modified Delphi Study
Annals of the American Thoracic Society
Abstract
RATIONALE: Advanced interventions are available for patients with more severe COPD despite guideline-recommended therapies, yet this population is heterogeneously defined and inconsistently recognized, and a standardized work-up is lacking, which could lead to mismanagement. OBJECTIVES: To formulate a new, expert-based consensus definition of severe COPD and a minimal set of diagnostics and characteristics to be assessed in the work-up of these patients. METHODS: A modified Delphi study with two online rounds was conducted between June 2024 and January 2025 with 55 international COPD experts representing all areas of disease management. Sixty-seven (round 1) and 20 (round 2) statements were tested in seven domains: (A) the need for a definition, (B) symptoms, (C) functional impairment, (D) quality of life, (E) physiological impairment, (F) framework definition, and (G) risk factors. Consensus was defined as ≥ 75% agreement. RESULTS: Consensus was reached for 46 (69%) statements in round 1 and 15 (75%) in round 2. Among patients with confirmed COPD, severe COPD was defined as: (1) persistent symptoms, functional impairment, or severely reduced quality of life; (2) despite optimal treatment and not due to comorbidities; and (3) including at least one clinical characteristic: severe airflow obstruction, severely impaired diffusion capacity, severe hyperinflation, frequent exacerbations, chronic respiratory insufficiency, pulmonary hypertension related to COPD, or cachexia or unintentional weight loss related to COPD. The proposed standardized work-up comprised: (1) assessment of patient-reported outcomes for symptoms, quality of life, anxiety and depression; (2) assessment of exacerbation frequency and severity; (3) comprehensive diagnostic testing, including lung function testing, blood gas analysis, imaging, cardiac assessment, and exercise-tolerance testing; and (4) assessment of risk factors for more severe and progressive disease. CONCLUSIONS: Using expert consensus, we devised an internationally-supported, proposed definition and work-up for 'severe COPD', accounting for disease heterogeneity. This definition may improve identification of the population and supports a structured evaluation of this often under-recognized and potentially undertreated population. Future studies are warranted to determine its clinical impact, prognostic value, and utility in research.
Authors 51
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University Medical Center Groningen · University of Groningen
Affiliation as printed
University of Groningen, Groningen, the Netherlands; Department of Respiratory Diseases, STZ Centre of Excellence for Asthma, COPD & Respiratory Allergy, Franciscus Hospital University of Groningen, University Medical Center Groningen, department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; Groningen Research Institute of Asthma and COPD (GRIAC), , Rotterdam, the
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University Medical Center Groningen
Affiliation as printed
University of Groningen University of Groningen, University Medical Center Groningen, department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; Groningen Research Institute of Asthma and COPD (GRIAC), , Groningen, the
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University Medical Center Groningen
Affiliation as printed
University of Groningen University of Groningen, University Medical Center Groningen, department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; Groningen Research Institute of Asthma and COPD (GRIAC), , Groningen, the
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Maastricht University Medical Centre · Maastricht University
Affiliation as printed
Maastricht University Medical Center Department of Research & Development, Ciro, Horn, the Netherlands; Department of Respiratory Medicine, , Maastricht, the
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Affiliation as printed
Erasmus University Medical Center Department of Respiratory Medicine and Transplantation Institute, , Rotterdam, the
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Department of Health · Department of Health Services
Affiliation as printed
Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands Department of Research & Development, Ciro, Horn, the Netherlands; Department of Health Services Research and Department of Family Medicine, ; Department of Expertise and Treatment, Proteion, Horn, the
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Affiliation as printed
Longfonds , Amersfoort, the
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University Medical Center Groningen
Affiliation as printed
University of Groningen University of Groningen, University Medical Center Groningen, department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; Groningen Research Institute of Asthma and COPD (GRIAC), , Groningen, the
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Hospital Clínic de Barcelona · Institut d'Investigacions Biomèdiques de Barcelona · Universitat de Barcelona
Affiliation as printed
Barcelona, Spain; FCRB-IDIBAPS, Barcelona, Spain; CIBERES Medicine Department, University of Barcelona, Barcelona, Spain; Respiratory Institute, Clinic Barcelona, , Madrid,
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NewYork–Presbyterian Hospital · Columbia University Irving Medical Center
Affiliation as printed
Columbia University Irving Medical Center, New York-Presbyterian Hospital , New York,
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University of Alabama at Birmingham
Affiliation as printed
University of Alabama at Birmingham Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, USA; Center for Lung Analytics and Imaging Research, , Birmingham,
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Spaarne Ziekenhuis · Spaarne Gasthuis
Affiliation as printed
Spaarne Gasthuis Department of Pulmonary Medicine, , Haarlem, the
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Affiliation as printed
Erasmus University Medical Center Department of Respiratory Medicine, University Hospital Ghent, Ghent, Belgium; Department of Respiratory Medicine, , Rotterdam, the
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Cardiovascular Clinical Science Foundation
Affiliation as printed
Director Clinical Research Foundation , Boston, Massachusetts,
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Affiliation as printed
KU Leuven Respiratory Division, University Hospitals Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery, , Leuven,
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Affiliation as printed
Temple University Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, , Philadelphia,
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Michael Dreher Aachen
Affiliation as printed
University Hospital Aachen Department of Pneumonology and Intensive Care Medicine, , Aachen,
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Affiliation as printed
University of Ferrara Section of Respiratory Medicine, Department of Translational Medicine, , Ferrara,
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Medizinische Hochschule Hannover
Affiliation as printed
Hannover Medical School Department of Respiratory Medicine and Infectious Diseases, , Hannover,
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Guy's and St Thomas' NHS Foundation Trust
Affiliation as printed
King's College London Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK; Centre for Human and Applied Physiological Sciences, ,
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Affiliation as printed
Alfred Health Respiratory Research@Alfred, School of Translational Medicine, Monash University, Melbourne, Australia; Institute for Breathing and Sleep, Melbourne, Australia; Department of Physiotherapy, , Melbourne,
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Royal Brompton Hospital · Lung Institute
Affiliation as printed
National Heart and Lung Institute, Imperial College, Royal Brompton Hospital Campus , London,
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Affiliation as printed
UCL Respiratory, University College London , London,
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Affiliation as printed
Health and Human Sciences Macquarie University, Faculty of Medicine, , Sydney, New South Wales,
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Affiliation as printed
KU Leuven Respiratory Division, University Hospitals Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery, , Leuven,
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University Medical Center Groningen
Affiliation as printed
University of Groningen University of Groningen, University Medical Center Groningen, department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; Groningen Research Institute of Asthma and COPD (GRIAC), , Groningen, the
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University Medical Center Groningen · University of Groningen · General Practitioners Research Institute
Affiliation as printed
Groningen Research Institute of Asthma and COPD (GRIAC), University of Groningen, Groningen, the Netherlands; University of Groningen, University Medical Center Groningen, department of Pulmonary Diseases and Tuberculosis General Practitioners Research Institute, Groningen, the Netherlands; Observational and Pragmatic Research Institute, Singapore, Singapore; , Groningen, the
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Stellenbosch University · Tygerberg Hospital
Affiliation as printed
Stellenbosch University and Tygerberg Hospital Division of Pulmonology, Department of Medicine, , Cape Town,
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Affiliation as printed
University of Antwerp Department of Pneumology, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Pediatrics, , Antwerp,
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Affiliation as printed
Cleveland Clinic Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, , Cleveland, Ohio,
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Affiliation as printed
University of Padova and AOPD Department of Cardio-Thoracic and Vascular Sciences, , Padua,
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St. Marianna University School of Medicine
Affiliation as printed
St. Marianna University School of Medicine Department of Respiratory Diseases, , Kawasaki,
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Vall d'Hebron Institut de Recerca
Affiliation as printed
Vall d'Hebron Barcelona Hospital Campus Pneumology Department, Hospital Universitari Vall d'Hebron; Vall d'Hebron Institut de Recerca (VHIR), , Barcelona,
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Spaarne Ziekenhuis · Spaarne Gasthuis
Affiliation as printed
Spaarne Gasthuis Department of Pulmonary Medicine, , Haarlem, The
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St. Joseph’s Healthcare Hamilton
Affiliation as printed
McMaster University Firestone Institute for Respiratory Health, St Joseph's Healthcare Hamilton, Hamilton, Canada; Department of Medicine, Division of Respirology, , Hamilton,
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Universidade Federal do Rio Grande do Sul · Hospital de Clínicas de Porto Alegre
Affiliation as printed
Universidade Federal do Rio Grande do Sul (UFRGS) Pulmonology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil; Medical School, , Porto Alegre,
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Affiliation as printed
Usher Institute, The University of Edinburgh , Edinburgh,
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Universidade Estadual de Londrina
Affiliation as printed
Universidade Estadual de Londrina Departamento de Fisioterapia, Laboratório de Pesquisa em Fisioterapia Respiratória (LFIP), , Londrina, Brasil
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Affiliation as printed
Lausanne University Hospital Division of Pulmonary Diseases, Department of Medicine, , Lausanne,
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Université Paris Cité · Hôpital Cochin · Assistance Publique – Hôpitaux de Paris
Affiliation as printed
Hôpital et Institut Cochin Service de Pneumologie, Assistance Publique-Hôpitaux de Paris Centre, Université Paris Cité, , Paris,
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Affiliation as printed
King's College London King's Centre for Lung Health, Peter Gorer Department of Immunobiology, , London,
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Affiliation as printed
Maastricht University Department of Respiratory Medicine, NUTRIM Institute of Nutrition and Translational Research in Metabolism, , Maastricht, the
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Manchester University NHS Foundation Trust · Medicines Evaluation Unit
Affiliation as printed
Manchester University NHS Foundation Trust, Manchester, UK; Medicines Evaluation Unit Division of Immunology, Immunity to Infection and Respiratory Medicine, The University of Manchester, Manchester, UK; North West Lung Centre, , Wythenshawe, Greater Manchester,
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University of Freiburg · University Medical Center Freiburg
Affiliation as printed
University of Freiburg Clinic of Respiratory Medicine, Faculty of Medicine, , Freiburg,
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Institute of Infection and Immunity
Affiliation as printed
The University of Manchester Division of Immunology, Immunity to Infection and Respiratory Medicine, , Manchester,
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Philipps University of Marburg · German Center for Lung Research
Affiliation as printed
University of Marburg, Baldingerstrasse, Marburg Department of Medicine, Pulmonary, and Critical Care Medicine, German Center for Lung Research (DZL), , 35033, Marburg,
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Affiliation as printed
KU Leuven Respiratory Division, University Hospitals Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery, , Leuven,
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Affiliation as printed
University Witten/Herdecke Department of Pneumology, Kliniken der Stadt Köln gGmbH, , Cologne,
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Emily F A van ’t Wout Aachen
Leiden University Medical Center
Affiliation as printed
Leiden University Medical Center Department of Pulmonology, , Leiden, The
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Affiliation as printed
Franciscus Hospital Department of Respiratory Diseases, STZ Centre of Excellence for Asthma, COPD & Respiratory Allergy, , Rotterdam, the
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Pieter-Paul W. Hekking corresponding
Affiliation as printed
University of Amsterdam Department of Respiratory Diseases, STZ Centre of Excellence for Asthma, COPD & Respiratory Allergy, Franciscus Hospital, Rotterdam, the Netherlands; Department of Respiratory Medicine, Academic Medical Centre, , Amsterdam, the