Exacerbations in airway disease – can we get better at prediction and prevention?

2026: ERS Barcelona

Andningsvägar Klinisk praxis

DELA MED SIG

Why do exacerbations remain a challenge in both asthma and COPD? This was discussed in a symposium about gaps in current care. Of particular interest was the heterogeneity of exacerbations and the need to understand drivers of individual events. Earlier identification of patients at risk and a more individualized approach may help improve prevention. Patients need access to the right information, support and access to help when symptoms worsen.

SESSION:
Critical challenges in airway disease: gaps in our science to identifying patients at risk of disease worsening
Speakers
Marc Miravitlles (Spain), Florence Schleich (Belgium), Alexander Mathioudakis (United Kingdom), Luciano Cattani (Italy), Myriam Van de velde (Belgium).

Ingvild Bjellmo Johnsen
Medical Advisor, Chiesi Nordic

One size does not fit all

At the symposium “Critical challenges in airway disease: gaps in our science to identifying patients at risk of disease worsening”, Marc Miravitlles opened by outlining the heterogeneity of exacerbations across airway diseases.  

Exacerbations differ in etiology, severity and clinical presentation, and importantly, many patients continue to exacerbate on preventive treatment¹.

Exacerbations are inflammatory events, but that inflammation does not come “out of the blue”, Miravitlles remarked. We do not only need to treat the inflammation, we also need to understand what is causing the inflammation. In COPD, eosinophilic inflammation represents one part of the picture, while infection may be particularly important in many other patients^2,3. Chronic bronchial infection may contribute to frequent exacerbations, development of bronchiectasis and further lung damage⁴. Due to the interplay between viral and bacterial infections, bacteria in the lower airways should not simply be dismissed as “colonization”.

Understanding the phenotype and the underlying cause of the exacerbation is important if we want to improve prevention. This calls for individualized treatment: one size does not fit all.

Severe asthma: Why do exacerbations persist?

Why do some patients with severe asthma continue to experience exacerbations despite biologic treatment? Florence Schleich explored this question, by focusing on three key questions: Is type 2 inflammation still active? Is infection driving the exacerbation? And is the current biologic adequately suppressing its intended target?⁵ She presented data showing that residual exacerbations can have different inflammatory profiles. Some remain eosinophilic, while others are more characterized by infection or neutrophilic inflammation⁶. Of particular interest was the message that we should phenotype the exacerbation itself and not automatically assume that the mechanism is the same as for the underlying asthma.

Comorbidities, including nasal disease, bronchiectasis, fungal sensitization, obesity, GERD, OSA and anxiety were mentioned as modifiable factors contributing to residual exacerbations. Environmental triggers and poor adherence to inhaled treatment may also play a role⁷.

“We have to take a comprehensive approach to assess the potential contributors to these residual exacerbations and to go for a personalized management.”

Florence Schleich

From prediction to prevention

Why is COPD progression so difficult to predict? asked Alexander Mathioudakis before pointing out three main challenges: the heterogeneity of the disease, the randomness of acute events, and the fact that disease progression can mean very different things, including lung function decline, exacerbations, functional decline and mortality. Each patient represents a unique combination of pulmonary, extrapulmonary and behavioural or environmental traits, making prediction at the individual patient level particularly challenging. Exacerbation history remains one of the strongest predictors of future exacerbations, but the obvious limitation is that the patient has already suffered from an event before the risk is identified⁸. Presence of mucus plugging has been associated with adverse outcomes⁹  and is now emerging as a new prognostic marker in COPD.

The prevention gap

COPD is still often diagnosed too late, so by the time the patient is diagnosed and characterized, significant irreversible damage may already have occurred. COPD is a complex disease, but due to the high prevalence, not all patients have access to specialist assessment.  

An important message was therefore the need to identify earlier which patients require more attention and more specialized assessment¹⁰. Better integration between primary and secondary care may be one way forward. Achieving disease stability early may have importance for long-term outcomes¹¹. Prediction in itself is therefore not enough, we also need to be able to act on the information.

Patient perspectives

The final part of the session was given by two patient representatives. Luciano Cattani, living with severe asthma, described the uncertainty associated with an exacerbation. What should I do? When should I seek help? Who should I contact? To help patients to act earlier and with more confidence, he suggested better patient education and practical tools for managing worsening symptoms.

Myriam Van de Velde, living with COPD, highlighted the importance of self-management, but also described the challenge of navigating between specialists working on separate “islands”. Her message was that we need to look at the whole patient and not only one organ or one diagnosis.

The bottom line

The session highlighted that preventing exacerbations requires more than treating symptoms or inflammation. We need to understand what is driving the exacerbation in the individual patient, identify patients at risk earlier and make sure that we act on that information.

ID 24904-22.09.2026