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Recent studies have emphasized the difficulty of early detection of chronic obstructive pulmonary disease (COPD) in symptomatic smokers with normal routine spirometry. This includes post-bronchodilator normal forced expiratory volume in 1 second (FEV 1 )(L)≥80% predicted, forced vital capacity (FVC)(L)≥80% predicted, and FEV 1 /FVC ≥70% or greater than age corrected lower limit of normal (LLN). However, in COPD the pathologic site of small airway obstruction and emphysema begins in the small peripheral airways ≤2 mm id which normally contribute &lt;20% of total airway resistance.

Normal Routine Spirometry Can Mask COPD/Emphysema in Symptomatic Smokers