HOW CAN I
IDENTIFY PATIENTS
MOST AT RISK?

Exacerbations are frequently under-recognised or under-reported by patients and can therefore be under-treated.^12-14 It’s also important to keep in mind that even if a patient hasn’t exhibited an exacerbation, they are still at risk of one especially if they have experienced symptoms.¹⁰

There are common risk factors that can help identify patients at risk of a COPD exacerbation, including:

Previous Exacerbations

A history of exacerbations is the strongest predictor of future exacerbation risk. The risk of re-hospitalisation or death also increases substantially after a first severe COPD exacerbation, and with each subsequent event.¹⁰

Download the flare-up checklist

Additional Markers to Consider (Biological)

Patients with raised eosinophil counts not on an ICS are at higher risk of exacerbating.³¹

Symptom Burden

Increasing symptoms such as dyspnea or frequent productive cough are associated with an increased risk of exacerbations.^10,32*

Lung Function

Poor lung function (i.e., FEV1) is associated with a greater risk of exacerbations, however, patients with a higher FEV1 (GOLD Stage 1) may lose more lung function following an exacerbation than patients with more severe COPD.^2,33

Syndemics

COPD patients with other concomitant conditions such as cancer, heart failure, dyspepsia or asthma are at greater risk of experiencing frequent exacerbations.³⁴ Emerging data suggests a syndemic occurrence between COPD and cardiovascular disease, with fundamental pathobiological links between the heart and lungs causing an aggregation of the two diseases and leading to a worsening in burden and prognosis of disease.⁴

It’s never too early to Act on COPD

Put prevention of exacerbation and early death at the centre of COPD management.

American Lung Foundation. Heart-Lung Relationship. Blog, February 13, 2023. https://www.lung.org/blog/heart-lung-relationship
Watz H, et al. Respir Res 2018;19:251
Suissa S, et al. Thorax 2012;67:957–963
Donaldson GC, et al. Chest 2010;137:1091–1097
Kunisaki KM, et al. Am J Respir Crit Care Med 2018;198:51–57
Rothnie KJ, et al. Am J Respir Crit Care Med 2018;198:464–471
Hurst JR, et al. Eur J Int Med 2020;73:1–6
Pullen R, et al. Int J Chron Obstruct Pulmon Dis 2021;16:2301–2322
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for prevention, diagnosis and management of COPD. 2025. https://goldcopd.org/2025-gold-report/ (Accessed July 2025)
Müllerová H, et al. BMJ Open 2014;4:e006171
Hughes R, et al. Respir Med 2022;200:106921
Singh D, et al. Int J Chron Obstruct Pulmon Dis 2021;16:3009–3016
Barnes N, et al. BMC Pulm Med 2013;13:54
Pavord ID, et al. Int J Chron Obstruct Pulmon Dis 2016;11(special issue):21–30
Graul EL, et al. Am J Respir Crit Care Med 2023; doi: 10.1164/rccm.202307-1122OC (Epub ahead of print, Dec 21)
Adeloye D, et al. Lancet Respir Med 2022;10:447–458
Hurst JR, et al. N Engl J Med 2010;363(12):1128–1138
ClinicalTrials.gov. NCT00292552. Accessed March 2024
Wallace AE, et al. J Manag Care Spec Pharm 2019;25(2):205–217
Koblizek V, et al. Eur Respir J 2017;49(5):1601446
Jones PW, et al. Am J Respir Crit Care Med 2015;191:A2532
Matsunaga K, et al. Respir Investig 2015;53(2):82–85
Hoogendoorn M, et al. Int J Chron Obstruct Pulmon Dis 2017;12:3183–3194
Tashkin DP, et al. N Engl J Med 2008;359(15):1543–1554
Roche N, et al. Eur Respir J 2017;50:OA1487
Kania A, et al. Int J Chron Obstruct Pulmon Dis 2018;13:1613–1621
Halpin DMG, et al. Respir Med 2017;128:85–91
Rothnie KJ, et al. Ann Am Thorac Soc 2018;15(8):935–946. doi: 10.1513/AnnalsATS.201710-815OC
Mannino DM, et al. Respir Med 2006;100:115–122
Hughes R, et al. Respir Med 2022;200:106921
Bafadhel M, et al. Lancet Respir Med 2018;6:117–126
Lindberg A, et al. Respir Med 2015;109:88–95
Dransfield MT, et al. Am J Respir Crit Care Med 2017;195(3):324–330
Westerik JAM, et al. Respir Res 2017;18:31
Kessler R, et al. CHEST 2006;130(1):133–142
Wedzicha JA, Mackay AJ, Singh R. COPD exacerbations: impact and prevention. Breathe 2013;9(6):434–440
Ji Z, Jareño-Esteban JJ, de Miguel-Díez J. Role of Vaccines in COPD Patients. Open Respir Arch 2022;4(3):100191
Simon S, Joean O, Welte T, Rademacher J. The role of vaccination in COPD: influenza, SARS-CoV-2, pneumococcus, pertussis, RSV and varicella zoster virus. Eur Respir Rev 2023;32(169)
Hogea S-P, Tudorache E, Fildan AP, Fira-Mladinescu O, Marc M, Oancea C. Risk factors of chronic obstructive pulmonary disease exacerbations. Clin Respir J 2020;14:183–197
Linden D, Guo-Parke H, Coyle PV, Fairley D, McAuley DF, Taggart CC, Kidney J. Respiratory viral infection: a potential "missing link" in the pathogenesis of COPD. Eur Respir Rev 2019;28(151):180063
Papi A, Bellettato CM, Braccioni F, Romagnoli M, Casolari P, Caramori G, Fabbri LM, Johnston SL. Infections and airway inflammation in chronic obstructive pulmonary disease severe exacerbations. Am J Respir Crit Care Med 2006;173(10):1114–1121. doi: 10.1164/rccm.200506-859OC
Bouquet J, Tabor DE, Silver JS, Nair V, Tovchigrechko A, Griffin MP, et al. Microbial burden and viral exacerbations in a longitudinal multicenter COPD cohort. Respir Res 2020;21:1–13. doi: 10.1186/s12931-020-01340-0
Mathioudakis AG, Janssens W, Sivapalan P, Singanayagam A, Dransfield MT, Jensen J-US, et al. Acute exacerbations of chronic obstructive pulmonary disease: in search of diagnostic biomarkers and treatable traits. Thorax 2020;75(6):520–527
Frickmann H, Jungblut S, Hirche TO, Groß U, Kuhns M, Zautner AE. The influence of virus infections on the course of COPD. Eur J Microbiol Immunol (Bp) 2012;2(3):176–185. doi: 10.1556/EuJMI.2.2012.3.2
Dimopoulos G, Lerikou M, Tsiodras S, Chranioti A, Perros E, Anagnostopoulou U, Armaganidis A, Karakitsos P. Viral epidemiology of acute exacerbations of chronic obstructive pulmonary disease. Pulm Pharmacol Ther 2012;25(1):12–18. doi: 10.1016/j.pupt.2011.08.004
Bafadhel M, McKenna S, Terry S, et al. Acute exacerbations of chronic obstructive pulmonary disease: identification of biologic clusters and their biomarkers. Am J Respir Crit Care Med 2011;184(6):662–671
Aaron SD, Donaldson GC, Whitmore GA, Hurst JR, Ramsay T, Wedzicha JA. Time course and pattern of COPD exacerbation onset. Thorax 2012;67(3):238–243
Wilkinson TM, Hurst JR, Perera WR, Wilks M, Donaldson GC, Wedzicha JA. Effect of interactions between lower airway bacterial and rhinoviral infection in exacerbations of COPD. Chest 2006;129(2):317–324
Falsey AR, Walsh EE, Esser MT, Shoemaker K, Yu L, Griffin MP. Respiratory syncytial virus-associated illness in adults with advanced chronic obstructive pulmonary disease and/or congestive heart failure. J Med Virol 2019;91:65–71
Sethi S, Murphy TF. Infection in the pathogenesis and course of chronic obstructive pulmonary disease. N Engl J Med 2008;359:2355–2365

^* In some patients, lung function did not recover to pre-exacerbation levels by eight weeks after the start of the moderate exacerbation

^†Following a severe exacerbation, the rate of severe exacerbation increased and the time to subsequent exacerbations decreased

^‡Singh D, Han MK, Hawkins NM, et al. Implications of Cardiopulmonary Risk for the Management of COPD: A Narrative Review. Adv Ther (2024). https://doi.org/10.1007/s12325-024-02855-4

^**In a study conducted on patients with moderately severe COPD and rigorously adjudicated CVD events

^***Cohort study evaluating severe COPD exacerbations and their association with mortality in 73,106 patients with their first severe COPD exacerbation requiring hospitalisation (patients identified 1990–2005, followed until death or 31 March 2007)

^****Irreversibly reduce lung function

^*****The relative risk of MI returned to near baseline, similar to any other post-exacerbation time interval

Welcome to AZMedical Science

HOW CAN I IDENTIFY PATIENTS MOST AT RISK?