Primary prevention

Multiple factors impact the risk of subsequent exacerbations and these vary among individual patients. Following COPD exacerbation, every effort should be made to both identify and mitigate potentially modifiable factors to reduce the risk of subsequent exacerbation events.

Previous exacerbation history is a key risk factor for future exacerbations.[1][55] People with a high burden of symptoms and history of frequent exacerbations are at particular risk of future exacerbations and mortality.[1][80] 

Offer smoking cessation advice and treatment to all people with COPD who smoke.[81] Smoking cessation can reduce the risk of exacerbations in people with COPD.[82] See our topic Smoking cessation.

Advise all patients to avoid other potential triggers such as wood smoke, dust, and other airborne pollutants.

A primary goal of treating stable COPD is to reduce symptoms and future risk of exacerbations.[1] Vaccinations can reduce the chance of COPD exacerbations; specifically consider the following.

  • Pneumonia: in the UK, all patients with COPD should receive pneumococcal immunisation with a single dose of PPV23.[83] Outside of the UK, many countries follow recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) that all patients >65 years of age should receive PCV13 and PPSV23. The PPSV23 is also recommended by GOLD for younger COPD patients with significant comorbid conditions including chronic heart or lung disease.[1]

    • Evidence from a Cochrane review showed that pneumococcal vaccination in people with COPD reduced the chance of an acute exacerbation (and additionally provided some protection against community-acquired pneumonia).[84] 

  • Influenza: all patients with COPD should be vaccinated against influenza virus to reduce COPD exacerbations.[1][85]

    • Evidence from randomised controlled trials showed that inactivated influenza vaccination had a clinically important and significant effect on influenza‐related exacerbations, and probably an effect on the total number of exacerbations, in people with COPD.[86]

  • Tetanus/diphtheria/pertussis: GOLD endorses the recommendation from the US Centers for Disease Control and Prevention that all patients with COPD who have not been vaccinated against tetanus/diphtheria/pertussis in adolescence should receive the Tdap vaccine.[1] However, bear in mind that this is not a current recommendation in some countries, including the UK.

Consider also prophylactic pharmacotherapy.

  • Consider using mucolytic agents to decrease exacerbations in people with COPD. Mucolytic agents may be beneficial in reducing days of disability per month and possibly hospitalisations.[87] The 2021 GOLD guideline states that treatment with mucolytic agents such as carbocisteine and acetylcysteine may be most beneficial for patients not on inhaled corticosteroids. GOLD also states that erdosteine may have a significant effect on (mild) exacerbations, irrespective of concurrent treatment with inhaled corticosteroids.[1] However, bear in mind that the National Institute for Health and Care Excellence in the UK does not recommend routinely using mucolytics to prevent exacerbations in people with stable COPD.[88] 

  • A specialist team might consider prophylactic use of a macrolide antibiotic for preventing exacerbations on an individual patient basis. Although there appears to be some benefit of using macrolides in decreasing exacerbations, this is based on a limited number of studies, and concerns remain about antibiotic resistance with long-term use.[89] In clinical practice, prophylactic antibiotics are contraindicated in patients with previously isolated non‐tuberculous mycobacteria, due to the risk of developing resistant non‐tuberculous mycobacteria.

Secondary prevention

After an exacerbation, ensure the patient understands their usual treatment regimen and assess their inhaler technique. Discuss the importance of adhering to their routine COPD medication and explain that they may develop worsening signs and symptoms if they don’t continue with their usual regimen as prescribed.[241] A goal of managing stable COPD is to reduce further exacerbations.[1]

In addition, advise the patient to continue with other measures that will contribute to the prevention of further exacerbations, such as seasonal vaccines, smoking cessation, and trigger avoidance; consider prophylactic pharmacotherapy as appropriate. For more on this, see Primary prevention

Provide vitamin D supplementation, if required. Supplementation of patients with severe deficiency results in a reduction in exacerbations and hospitalisation.[1]

People with COPD tend to be less physically active than those without the condition, and low physical activity levels are associated with a faster rate of decline in lung function and increased hospitalisations for COPD exacerbations over time.[235][242][243] Encourage patients to participate in pulmonary rehabilitation programmes, where available. Pulmonary rehabilitation is a multidisciplinary programme of care that involves physical rehabilitation as well as guidance on disease management, nutrition, and other lifestyle issues (e.g., smoking cessation, medicine compliance and inhaler technique, supplemental oxygen, and maintenance of physical activity).[150] These initiatives can improve exercise tolerance, physical ability, and quality of life, therefore playing an important role in the prevention of subsequent exacerbations.[149] 

Consider a hospital-at-home or assisted discharge scheme, where available, once the patient is stable.[88][147][148] [ Cochrane Clinical Answers logo ]  The decision over which patients are suitable for such schemes will need a team approach, as will the implementation of such schemes. Take patient factors and preferences into account.[88] Consider using a validated prognostic score, such as the DECAF score, to determine which patients are suitable for this approach.[147]

Outpatient follow-up of patients within 30 days of hospital discharge following acute exacerbations also helps prevent readmissions and relapse of disease.[244] Action plans can help patients recognise worsening symptoms, initiate earlier treatment, and reduce overall impact of exacerbations.[81][245] [ Cochrane Clinical Answers logo ]

Although tele-health is used in some regions for home-based disease monitoring and management intervention,[246] it is not currently recommended for exacerbation prevention.[1][81] Randomised controlled trials have suggested that the use of nurse-centred tele-assistance may decrease the occurrence of exacerbations of COPD, urgent care visits, and hospitalisation.[246] The use of such programmes may be cost-saving.[247] Other analyses have suggested that home tele-monitoring may prolong the time free of hospitalisations or accident and emergency department visits,[248] but the total number of hospitalisations may not be affected and another randomised controlled trial showed no clear beneficial effects.[249]

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