Recent years have witnessed major advances in lung imaging in patients with COPD. These include significant refinements in images obtained by computed tomography (CT) scans together with the introduction of new techniques and software that aim for obtaining the best image whilst using the lowest possible radiation dose. Magnetic resonance imaging (MRI) has also emerged as a useful radiation-free tool in assessing structural and more importantly functional derangements in patients with well-established COPD and smokers without COPD, even before the existence of overt changes in resting physiological lung function tests. Together, CT and MRI now allow objective quantification and assessment of structural changes within the airways, lung parenchyma and pulmonary vessels. Furthermore, CT and MRI can now provide objective assessments of regional lung ventilation and perfusion, and multinuclear MRI provides further insight into gas exchange; this can help in structured decisions regarding treatment plans. These advances in chest imaging techniques have brought new insights into our understanding of disease pathophysiology and characterising different disease phenotypes. The present review discusses, in detail, the advances in lung imaging in patients with COPD and how structural and functional imaging are linked with common resting physiological tests and important clinical outcomes.

Novel structural and functional radiological markers derived from CT and MRI in patients with COPD are useful in disease phenotyping and therapeutic decisions. These parameters are linked with common physiological tests and important clinical outcomes. https://bit.ly/4aivrgo

Author contribution: All listed authors played a significant role in the content and writing of the manuscript. In addition, A.F. Elbehairy wrote the first draft and all authors accepted the final version of the manuscript.

Conflict of interest: A.F. Elbehairy has nothing to disclose. H. Marshall reports research funding from GlaxoSmithKline and meeting expenses from AstraZeneca. J.H. Naish has a part-time appointment with Bioxydyn Ltd. J.M. Wild is funded by the UKRI, NIHR, MRC and NIHR Sheffield Biomedical Research Centre, has investigator-led research funding from GlaxoSmithKline and AstraZeneca, and has provided consultancy for Vertex, Boehringer Ingelheim and AstraZeneca. G. Parraga acknowledges study funding from GlaxoSmithKline and AstraZeneca, honoraria from GlaxoSmithKline, AstraZeneca and Polarean, and travel support from GlaxoSmithKline and Polarean. A. Horsley reports personal fees from Vertex Pharmaceuticals and Mylan Pharmaceuticals, consulting fees from Vertex Pharmaceuticals, Boehringer Ingelheim and Roche Genentech, grants from JP Moulton Charitable Trust, EPSRC, CF Trust, Cystic Fibrosis Foundation and NIHR, and leadership roles with the Translational Research Collaboration and CF Trust Clinical Trials Accelerator Platform, outside the submitted work. J. Vestbo reports personal fees from ALK-Abelló, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline and Teva, outside the submitted work. A. Horsley and J. Vestbo are supported by the NIHR Manchester Biomedical Research Centre and Clinical Research Facility.