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It is well established that smokers with mild airway obstruction, as spirometrically defined, represent the vast majority of patients with <jats:styled-content style=\"fixed-case\">COPD<\/jats:styled-content>, yet this population has not been extensively studied. An insidious preclinical course means that mild <jats:styled-content style=\"fixed-case\">COPD<\/jats:styled-content> is both underdiagnosed and undertreated. In this context, recent studies have confirmed that even patients with mild <jats:styled-content style=\"fixed-case\">COPD<\/jats:styled-content> can have extensive physiological impairment, which contributes to poor perceived health status compared with non\u2010smoking healthy controls. This review describes the heterogeneous pathophysiology that can exist in <jats:styled-content style=\"fixed-case\">COPD<\/jats:styled-content> patients with only mild airway obstruction on spirometry. It exposes the compensatory adaptations that develop in such patients to ensure that the respiratory system fulfils its primary task of maintaining adequate pulmonary gas exchange for the prevailing metabolic demand. It demonstrates that adaptations such as increased inspiratory neural drive to the diaphragm due to combined effects of increased mechanical loading and chemostimulation underscore the increased dyspnoea and exercise intolerance in this population. Finally, based on available evidence, we present what we believe is a sound physiological rationale for earlier diagnosis in this population.<\/jats:p>","DOI":"10.1111\/resp.12619","type":"journal-article","created":{"date-parts":[[2015,9,2]],"date-time":"2015-09-02T20:43:08Z","timestamp":1441226588000},"page":"211-223","source":"Crossref","is-referenced-by-count":35,"title":["Physiological impairment in mild <scp>COPD<\/scp>"],"prefix":"10.1111","volume":"21","author":[{"given":"Denis E.","family":"O'Donnell","sequence":"first","affiliation":[{"name":"Department of Medicine Division of Respiratory and Critical Care Medicine Queen's University and Kingston General Hospital  Kingston Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J. 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