This paper explores the natural history of chronic obstructive pulmonary disease (COPD), including our present understanding of COPD risk factors, phenotypes, and burden, along with COPD progression, including the traditional ‘accelerated lung function decline’ paradigm, to newer paradigms that include other factors. Questions remain unanswered, and there is considerable room for improvement. One of those questions is how the disease should best be defined. While this question has generated lively debate in the literature, it may not be the most important area with regard to advancing our understanding of the disease. The different phenotypes of COPD, particularly with regard to differential interventions and outcomes, is an area that should receive much more attention. Finally, a more holistic view of what comprises COPD progression, looking well beyond the traditional lung function decline paradigm, may also provide additional insights in how to better care for our patients.