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. People with a high burden of symptoms and history of frequent exacerbations are at particular risk of future exacerbations and mortality.
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. 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. 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.
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).
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.
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. 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. 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. 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.
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. 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.