In 1976, Fletcher et al. published a monograph summarizing theresults of an 8-year observational study of the relationshipbetween cigarette smoking, chronic expectoration, and the developmentof irreversible airflow obstruction.1 At that time, the nomenclaturefor chronic obstructive pulmonary disease (COPD) was confusing.COPD was understood to include chronic bronchitis and emphysema,but the definitions of these two entities contained no mentionof airflow obstruction. The clinical paradigm described patientsas either "blue bloaters," who had chronic airway inflammationand a propensity for resting hypercapnia, and "pink puffers,"who had airspace destruction and preserved resting arterialoxygenation.
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