Unstable exacerbating COPD: Unaddressed modifiable risk factors or unstable despite optimised care

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are major contributors to morbidity, mortality and accelerated lung function decline. While many exacerbations may be driven by modifiable risk factors, a subset of patients continue to exacerbate despite optimised guideline-based management, potentially identifying a population suitable for advanced therapeutic strategies.

To assess the proportion of patients with unstable COPD who experience exacerbations despite optimised care and to identify unaddressed modifiable risk factors.

This cross-sectional study enrolled patients on double or triple inhaled therapy admitted with AECOPD to Bispebjerg Hospital, Denmark, over 12 months. Six to twelve weeks after discharge, participants underwent a systematic assessment of disease phenotype, treatment barriers, comorbidities, and type 2 inflammation biomarkers.

Among 103 patients hospitalised with AECOPD, 34% met criteria for unstable COPD despite optimised care; of these 33% had blood eosinophil counts ≥0.3 × 10⁹ cells/L. Poor adherence (49.5%) and critical errors in inhalation technique (21.4%) were common. One in five patients had at least one undiagnosed or unaddressed comorbidity with the potential to mimic or increase the risk of exacerbations.

One third of patients with AECOPD had unstable disease despite optimised management. Implementing structured clinical pathways is essential to systematically address modifiable treatment barriers and comorbidities contributing to recurrent exacerbations, and to identify candidates for advanced therapies.