Abstract Background Chronic obstructive pulmonary disease (COPD) is a heterogeneous condition characterized by progressive airflow limitation. The management paradigm is shifting from reactive symptom control toward proactive strategies centered on “disease activity”. Mucus plugs Score (MPS), derived from computed tomography (CT), provides a visual assessment of occlusive airway plugs. As a promising alternative imaging biomarker, MPS correlates with disease activity and may guide precision interventions to achieve “low disease activity state (LDAS)”. Objective This study explores the comprehensive utility of MPS as a novel imaging biomarker in COPD, specifically for assessing disease activity, optimizing risk stratification for exacerbations and mortality, and guiding individualized therapeutic strategies. Methods A comprehensive literature search was conducted in PubMed and Web of Science for articles published from database inception through March 2026. The search strategy employed a combination of MeSH terms and keywords, including “Chronic Obstructive Pulmonary Diseases”, “Chronic Obstructive Lung Disease”, “Pulmonary Disease, Chronic Obstructive”, “Chronic Obstructive Airway Disease”, “COAD”, “COPD”, “Airflow Obstruction, Chronic”, “Chronic Airflow Obstructions”, “mucus plugs”, “mucus plugging”, “mucus plugs score”, “MPS” and “disease activity”. Articles were included based on their relevance to CT-detected mucus plugs, pathophysiology, and associated clinical outcomes in COPD. Priority was given to randomized controlled trials, prospective or retrospective observational cohorts, and high-quality mechanistic studies. Non-peer-reviewed materials and duplicate reports were excluded. Results Mucus plugs formation is a complex pathophysiological process involving mucus hypersecretion, impaired mucociliary clearance, and inflammatory cross-linking. Together, these mechanisms produce highly viscous, occlusive obstructions. Recent longitudinal cohort studies confirm that a high MPS is an independent risk factor for adverse clinical outcomes in COPD, including increased frequency of moderate-to-severe exacerbations, accelerated annual decline in FEV₁, and elevated all-cause mortality. Based on this evidence, MPS is thus recognized as a biomarker associated with disease progression and a potential factor in its worsening. Notably, “silent” mucus plugs in asymptomatic patients predict rapid progression and poor prognosis, presenting risks comparable, or even worse than symptomatic phenotypes. Conclusion MPS is a promising imaging biomarker that quantifies the burden of airway obstruction and reflects the disease activity of COPD. It may offer a more objective and direct assessment of COPD disease activity, serving as a valuable complement to traditional clinical indicators. Furthermore, our analysis demonstrates that MPS can identify high-risk “silent” asymptomatic patients who are otherwise overlooked by standard symptom-based assessments. MPS can independently predicts the risk of acute exacerbations, accelerated decline in FEV₁, and all-cause mortality, facilitating superior risk stratification. By identifying mucus plugs as a “treatable trait”, this biomarker enables a more precise targeted application of mucoactive and biologic therapies. We propose that MPS could serves as a complementary clinical tool for achieving the management goal of LDAS and improving long-term prognostic outcomes in patients with COPD.
Qian et al. (Tue,) studied this question.