Precision treatment of COPD based on novel imaging phenotypes: a treatable traits approach

Chronic obstructive pulmonary disease (COPD) is a heterogeneous syndrome. Spirometry, while diagnostic, inadequately characterizes disease complexity. This review explores how thoracic imaging, particularly computed tomography and magnetic resonance imaging, may help identify specific pulmonary "treatable traits" that could inform future precision management approaches. We detail four core imaging phenotypes: emphysema, small airway disease, airway mucus plugs, and airway wall thickening. For each, we discuss validated and emerging quantitative biomarkers-such as the Parametric Response Map, total airway count, mucus plug score, Pi10, and PiSlope-that facilitate phenotypic stratification and prognostication. We further describe two distinct disease trajectories ("Tissue-Airway" and "Airway-Tissue") revealed by progression modeling. Critically, we discuss potential links between these imaging-defined traits to targeted therapeutic strategies, including ultra-fine particle inhalers for small airway disease, mucus clearance strategies, and CT-guided lung volume reduction for emphysema. Despite significant progress, challenges remain in standardizing measurements, validating clinical utility, and integrating imaging biomarkers into routine care. Future integration of artificial intelligence and multimodal imaging holds promise for advancing COPD management towards true personalized medicine.