ERS Presidential Lecture

"Advancing COPD Care: From Phenotypes to Targeting Treatable Traits Through Precision Medicine Chronic obstructive pulmonary disease (COPD) is a heterogeneous condition characterised by substantial variability in clinical presentation, underlying biological mechanisms, disease trajectory and response to treatment. This heterogeneity has challenged the traditional approach of classifying patients according to fixed clinical phenotypes and applying largely uniform treatment strategies. Increasing evidence supports a shift towards precision medicine, in which treatment decisions are guided by the identification of individual, measurable and clinically relevant treatable traits. The concept of treatable traits represents an evolution from phenotype-based classification towards a multidimensional assessment of the patient. Rather than assigning patients to mutually exclusive categories, this approach recognises that several clinically relevant traits may coexist within the same individual and may change over time. These traits can encompass pulmonary characteristics, such as airflow limitation, hyperinflation, emphysema, chronic bronchitis, bronchiectasis and chronic bronchial infection, as well as systemic and extrapulmonary features including cardiovascular disease, frailty, osteoporosis, skeletal muscle dysfunction, anxiety and depression, and physical inactivity. Importantly, treatable traits should not simply describe disease characteristics; they should identify clinically relevant abnormalities for which an effective intervention is available. This distinction is particularly relevant as therapeutic options for COPD continue to expand. Blood eosinophil counts, for example, can help identify patients who are more likely to benefit from inhaled corticosteroids and, more recently, from targeted biologic therapies. Similarly, frequent exacerbations, chronic bronchial infection, mucus hypersecretion, pulmonary hyperinflation and physical inactivity may each require different therapeutic strategies, ranging from pharmacological treatment to pulmonary rehabilitation, airway clearance, antimicrobial approaches or interventions aimed at reducing hyperinflation. The emergence of biologic therapies targeting specific inflammatory pathways represents an important step towards precision treatment in COPD. However, precision medicine should not be equated with precision pharmacotherapy. Its broader objective is to integrate clinical characteristics, biomarkers, imaging, physiological measurements, comorbidities, environmental exposures and patient-reported outcomes to construct an individualised disease profile and select interventions according to the dominant treatable traits. Future COPD management will therefore require dynamic rather than static patient characterisation. Treatable traits may evolve with disease progression, exacerbations, treatment and ageing, making repeated assessment essential. Digital health, artificial intelligence, multi-omics and increasingly accessible biomarkers may further improve phenotyping and prediction of treatment response. The transition from phenotypes to treatable traits offers an opportunity to move beyond a one-size-fits-all model of COPD care. The challenge now is to determine which traits are clinically meaningful, how they should be identified and prioritised, and whether treating them translates into better outcomes. Precision medicine in COPD should ultimately be judged not by the sophistication of patient classification, but by its capacity to deliver more effective, personalised and clinically meaningful care."