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Background Asthma–chronic obstructive pulmonary disease (COPD) overlap (ACO) patients experience exacerbations more frequently than those with asthma or COPD alone. Since low diffusing capacity of the lung for carbon monoxide (D LCO ) is known as a strong risk factor for severe exacerbation in COPD, D LCO  or a transfer coefficient of the lung for carbon monoxide (K CO ) is speculated to also be associated with the risk of exacerbations in ACO. Methods This study was conducted as an observational cohort survey at the National Hospital Organization Fukuoka National Hospital. D LCO  and K CO  were measured in 94 patients aged ≥ 40 years with a confirmed diagnosis of ACO. Multivariable-adjusted hazard ratios (HRs) for the exacerbation-free rate over one year were estimated and compared across the levels of D LCO  and K CO . Results Within one year, 33.3% of the cohort experienced exacerbations. After adjustment for potential confounders, low K CO  (&lt; 80% per predicted) was positively associated with the incidence of exacerbation (multivariable-adjusted HR = 3.71 (95% confidence interval 1.32–10.4)). The association between low D LCO  (&lt; 80% per predicted) and exacerbations showed similar trends, although it failed to reach statistical significance (multivariable-adjusted HR = 1.31 (95% confidence interval 0.55–3.11)). Conclusions Low K CO  was a significant risk factor for exacerbations among patients with ACO. Clinicians should be aware that ACO patients with impaired K CO  are at increased risk of exacerbations and that careful management in such a population is mandatory.

The association between transfer coefficient of the lung and the risk of exacerbation in asthma-COPD overlap: an observational cohort study