Article abstract Today chronic obstructive pulmonary disease (COPD) is a great burden to social costs, which will inevitably increase in the future. Because of the progressive nature of COPD, it is urgent to find effective strategies to improve the clinical course of the disease, mainly by an early diagnosis and early treatment. Bronchodilation has always been the key point of the pharmacological treatment of COPD. Despite all major randomized clinical trials, which included patients with nonreversible airway obstruction, statistically significant (but often nonclinically significant) bronchodilation was observed using inhaled long-acting beta2-agonist (LABA) or anticholinergic drugs. These results were associated with other positive effects on other patient-perceived outcomes (rate of exacerbations, exercise tolerance, and quality of life). When patients with a significant acute bronchodilation were also included in these studies (such as in the Understanding Potential Long-term Impacts on Function with Tiotropium [UPLIFT] trial), the increase in forced expiratory volume in 1 s (FEV1) by the addition of tiotropium on top of acute administration of high-dose salbutamol and ipratropium bromide (and the regular dosage of LABA and/or inhaled corticosteroids in almost two thirds of the patients as well) was clinically significant and, in particular, was persistent for the entire 4-year period of the study. This sustained bronchodilation was also associated with persistent reduction in the rate of exacerbations and in the severity of dyspnea; in addition, it provided a long-lasting improvement in health-related quality of life. In a subgroup of these patients, tiotropium was able to significantly reduce the decline in post-bronchodilator FEV1. Mechanisms of the positive effect of this sustained bronchodilation are not well known, but a positive influence of bronchodilation on exercise performance (with further positive consequences on deconditioning and systemic inflammation) or a prolonged prevention of the airway mechanical collapse (which may cause chronic airway damage) might explain the positive effects of persistent bronchodilation in patients with COPD. Therefore, the improvement in FEV1 still remains a main objective of the treatment in COPD, and all treatments able to significantly improve FEV1 are expected to be effective in improving the clinical course of the disease.