This article reviews the main factors influencing the pathophysiology, symptoms, and progression of chronic obstructive pulmonary disease (COPD), including dynamic hyperinflation, exacerbations, and comorbid illness. Key clinical trials and reviews were identified. After formal presentations to a panel of pulmonary specialists and primary care physicians, a series of concepts, studies, and practical clinical implications related to COPD progression were integrated into this article, the last in a 4-part mini-symposium. The main points of roundtable consensus were as follows: (1) COPD is characterized by declining pulmonary function as classically measured by forced expiratory volume in 1 second (FEV1), but the complex pathophysiology and the rationale for bronchodilator therapy are actually better understood in terms of progressive hyperinflation, both at rest (static) and worsening during exercise (dynamic) and exacerbations; (2) although COPD progression is often thought of as inevitable and continuous, the clinical course is actually quite variable and probably influenced by the frequency of exacerbations; (3) preventing exacerbations with pharmacologic and nonpharmacologic care can influence overall morbidity; (4) comorbidities such as lung cancer, cardiovascular disease, and skeletal muscle dysfunction also contribute to declining patient health; and (5) surgical lung volume reduction and lung transplantation should be considered for selected patients with very severe COPD. We conclude that the concept of COPD as a gradual but relentlessly progressive illness that is best monitored via FEV1 is outdated and likely compromises patient care. Many patients now being managed in primary care settings will benefit from an earlier, broad-based, and aggressive approach to management. © 2008 Elsevier Inc. All rights reserved.