Identification of imaging-based pulmonary and extrapulmonary treatable traits in COPD: a review

Chronic obstructive pulmonary disease (COPD) is characterized by marked pathological heterogeneity, and traditional pulmonary function tests fail to support precise individualized therapy. Imaging-defined treatable traits have emerged as a novel strategy for COPD precision management. This review comprehensively describes the imaging manifestations, quantitative metrics and clinical implications of treatable traits across COPD lung parenchyma, airways, pulmonary vessels and major comorbidities, with a focus on CT and MRI techniques. According to existing clinical evidence, imaging biomarkers and matched treatments are divided into three tiers. A number of validated imaging indicators can effectively guide stratified interventions, including pulmonary rehabilitation, medication, bronchoscopic intervention and surgery. Nevertheless, the clinical translation of imaging assessment is hindered by non-unified quantitative standards, technical limitations of advanced imaging equipment, insufficient prospective evidence, and the inability to differentiate reversible and irreversible lesions. Further efforts are required to standardize imaging protocols, carry out prospective clinical trials, optimize multi-modal imaging and artificial intelligence tools, and improve evaluation systems for COPD comorbidities. In conclusion, imaging-based treatable traits have great potential to refine COPD diagnosis and treatment, and further high-quality research is needed to facilitate its widespread clinical application.