biostudies-literatureDunican EMNIAID NIH HHSNIEHS NIH HHSNHLBI NIH HHS957-968https://www.ebi.ac.uk/biostudies/studies/S-EPMC8048745biostudies-literatureUnknown203(8)<b>Rationale:</b> The relative roles of mucus plugs and emphysema in mechanisms of airflow limitation and hypoxemia in smokers with chronic obstructive pulmonary disease (COPD) are uncertain.<b>Objectives:</b> To relate image-based measures of mucus plugs and emphysema to measures of airflow obstruction and oxygenation in patients with COPD.<b>Methods:</b> We analyzed computed tomographic (CT) lung images and lung function in participants in the Subpopulations and Intermediate Outcome Measures in COPD Study. Radiologists scored mucus plugs on CT lung images, and imaging software automatically quantified emphysema percentage. Unadjusted and adjusted relationships between mucus plug score, emphysema percentage, and lung function were determined using regression.<b>Measurements and Main Results:</b> Among 400 smokers, 229 (57%) had mucus plugs and 207 (52%) had emphysema, and subgroups could be identified with mucus-dominant and emphysema-dominant disease. Only 33% of smokers with high mucus plug scores had mucus symptoms. Mucus plug score and emphysema percentage were independently associated with lower values for FEV₁ and peripheral oxygen saturation (<i>P</i> < 0.001). The relationships between mucus plug score and lung function outcomes were strongest in smokers with limited emphysema (<i>P</i> < 0.001). Compared with smokers with low mucus plug scores, those with high scores had worse COPD Assessment Test scores (17.4 ± 7.7 vs. 14.4 ± 13.3), more frequent annual exacerbations (0.75 ± 1.1 vs. 0.43 ± 0.85), and shorter 6-minute-walk distance (329 ± 115 vs. 392 ± 117 m) (<i>P</i> < 0.001).<b>Conclusions:</b> Symptomatically silent mucus plugs are highly prevalent in smokers and independently associate with lung function outcomes. These data provide rationale for targeting patients with mucus-high/emphysema-low COPD in clinical trials of mucoactive treatments.Clinical trial registered with www.clinicaltrials.gov (NCT01969344).American journal of respiratory and critical care medicineMucus Plugs and Emphysema in the Pathophysiology of Airflow Obstruction and Hypoxemia in Smokers.PMC8048745P01 HL107202P30 ES005605R01 HL080414U01 HL137880HHSN268200900015CHHSN268200900016CHHSN268200900017CHHSN268200900018CHHSN268200900019CU24 HL141762P01 HL128191HHSN268200900020CU19 AI077439K23 HL123778HHSN268200900013CHHSN268200900014CGierada DSKrishnan JASchroeder JDHansel NNBarr RGAnderson WO'Neal WKHan MKDrummond MBPeters SPaine RCriner GJDunican EMHoffman EAHastie ATElicker BMChristenson SABoucher RCMartinez FJDoerschuk CMCooper CBBleecker ERLazarus SCOrtega VEWoodruff PGFahy JVSchiebler MLHenry TBowler RComellas ABarjaktarevic ICouper DDransfield MMcCulloch CEfalseMucus Plugs and Emphysema in the Pathophysiology of Airflow Obstruction and Hypoxemia in Smokers.<b>Rationale:</b> The relative roles of mucus plugs and emphysema in mechanisms of airflow limitation and hypoxemia in smokers with chronic obstructive pulmonary disease (COPD) are uncertain.<b>Objectives:</b> To relate image-based measures of mucus plugs and emphysema to measures of airflow obstruction and oxygenation in patients with COPD.<b>Methods:</b> We analyzed computed tomographic (CT) lung images and lung function in participants in the Subpopulations and Intermediate Outcome Measures in COPD Study. Radiologists scored mucus plugs on CT lung images, and imaging software automatically quantified emphysema percentage. Unadjusted and adjusted relationships between mucus plug score, emphysema percentage, and lung function were determined using regression.<b>Measurements and Main Results:</b> Among 400 smokers, 229 (57%) had mucus plugs and 207 (52%) had emphysema, and subgroups could be identified with mucus-dominant and emphysema-dominant disease. Only 33% of smokers with high mucus plug scores had mucus symptoms. Mucus plug score and emphysema percentage were independently associated with lower values for FEV₁ and peripheral oxygen saturation (<i>P</i> < 0.001). The relationships between mucus plug score and lung function outcomes were strongest in smokers with limited emphysema (<i>P</i> < 0.001). Compared with smokers with low mucus plug scores, those with high scores had worse COPD Assessment Test scores (17.4 ± 7.7 vs. 14.4 ± 13.3), more frequent annual exacerbations (0.75 ± 1.1 vs. 0.43 ± 0.85), and shorter 6-minute-walk distance (329 ± 115 vs. 392 ± 117 m) (<i>P</i> < 0.001).<b>Conclusions:</b> Symptomatically silent mucus plugs are highly prevalent in smokers and independently associate with lung function outcomes. These data provide rationale for targeting patients with mucus-high/emphysema-low COPD in clinical trials of mucoactive treatments.Clinical trial registered with www.clinicaltrials.gov (NCT01969344).2021-01-01T00:00:00Z2021 Apr2026-05-02T22:40:02.135Z2025-04-05T09:59:17.544ZS-EPMC80487453318055010.1164/rccm.202006-2248OC10.1164/rccm.202006-2248oc