Primary prevention

Given the detrimental impact of COPD exacerbations on the patient, every effort should be made to prevent their occurrence. Previous exacerbation history is a key risk factor for future exacerbations.[1][21]​​ However, multiple factors impact the risk of subsequent exacerbations and relevant factors vary among individual patients. Following COPD exacerbation, every effort should be made to both identify and intervene in potentially modifiable factors to reduce risk of subsequent exacerbation events. In addition to identifying and avoiding potential triggers, adjustments to pharmacotherapy may be warranted.

Smoking cessation (including electronic cigarettes)

  • Avoiding smoke and smoking cessation are the best measures not only to prevent the onset of COPD, but also to prevent progression of the severity of COPD.[82][83] More severe COPD is associated with both more frequent and more severe exacerbations.[21][94] Smoking cessation can also reduce risk of exacerbations, and smoking cessation, counseling, and treatment is recommended for people with COPD.[84][85]

  • Electronic cigarette use (nicotine or cannabis products) should also be avoided.

Trigger avoidance

  • Patients should also be advised to avoid other potential triggers, such as wood smoke, dust, and other airborne pollutants.

Immunization

  • There is evidence that influenza vaccination is effective in preventing complications of COPD, particularly among people with severe airflow obstruction.[95][96][97][98]​​​ Yearly influenza vaccine is recommended for adults with COPD.[85][99]​​[100]​​​​​ The benefits of pneumococcal vaccination in reducing overall morbidity from COPD (including exacerbations) is less clear, but the vaccine does reduce the risk of pneumococcal pneumonia.[85]​​[98][101]​​​ One updated Cochrane review concluded that pneumococcal vaccination in people with COPD reduced the chance of an acute exacerbation and provided some protection against community-acquired pneumonia.[102]​ Pneumococcal vaccinations are now approved for all adults ≥65 years and for adults ages 19-64 years if they have an underlying medical condition including COPD and emphysema.[103][104]

  • The indications and benefits of vaccination against influenza virus, and Streptococcus pneumoniae, should be discussed with the patient.[95][96][105]

  • Some data suggest that an oral Haemophilus influenzae vaccine may help reduce recurrent exacerbations of chronic bronchitis in selected patients.[106][107][108][109][110]​​ However, one Cochrane review analysis demonstrated that oral H influenzae vaccine did not significantly reduce the number or severity of exacerbations.[111]

  • The Advisory Committee on Immunization Practices (ACIP) recommends that in adults who are immunocompetent and ages 65 years or older, who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown as follows should receive one dose of the 15-valent pneumococcal conjugate vaccine (PCV15) or one dose of the 20-valent pneumococcal conjugate vaccine (PCV20). If PCV15 is used, this should be followed by a dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) given at least 1 year after the PCV15 dose. Adults ages 19 to 64 years with specific comorbidities (including COPD), immunocompromising conditions, cerebrospinal fluid (CSF) leak, or a cochlear implant should also be vaccinated according to this schedule. Adults who, at any age, have received PCV7 only (no longer manufactured) should also follow these recommendations.[112]​​

  • In June 2019 ACIP voted to no longer routinely recommend PCV13, a 13-valent pneumococcal conjugate vaccine, for all adults ages ≥65 years and now recommends that adults ages ≥65 years who previously have received PCV13 should complete their pneumococcal vaccine series by receiving either a single dose of PCV20 at an interval of ≥1 year after the PCV13 dose, or ≥ one dose of PPSV23 to complete their pneumococcal series. When PPSV23 is used, the minimum recommended interval between PS13 and PPSV23 is ≥8 weeks for adults with an immunocompromising condition, a CSF leak, or a cochlear implant, or ≥1 year for adults without these conditions.[112]​ Adults with an immunocompromising condition, CSF leak, or cochlear implant who have received both PCV13 and PPSV23 but with incomplete vaccination status are recommended to complete their pneumococcal vaccine series with either a single dose of PCV20 at least 5 years after the last pneumococcal vaccine or with ≥ one dose of PPSV23. Full details of the timings and schedules for these are outlined in the latest ACIP recommendations.[112]​​

  • The CDC recommends: vaccination against tetanus, diphtheria and pertussis (with Tdap or Td) in those who were not vaccinated in adolescence; and Zoster vaccine to protect against shingles for adults with COPD ages ≥50 years.​[100]​ The respiratory syncytial virus (RSV) vaccine is recommended by the CDC for certain patient groups (including those with COPD); check your local immunization schedule.[113]

Pharmacotherapy

  • A primary goal of treating stable COPD is to reduce symptoms and future risk of exacerbations. A stepwise approach to inhaled pharmacotherapy is recommended, based on symptoms and exacerbations.[1]

  • See COPD for further details on the management of stable COPD.

Supplemental oxygen and noninvasive ventilation

  • Assessment of oxygenation during rest, exertion, and sleep is warranted for individuals with recurrent acute exacerbations of symptoms. Episodes of hypoxemia may increase ventilatory demand and trigger dyspnea, dynamic hyperinflation, and potentially, respiratory failure.[114] Arterial blood gas testing is helpful to identify people who have ventilatory insufficiency contributing to their symptoms, and who may benefit from, and/or require, noninvasive ventilation.[1]

Emerging evidence from observational studies conducted during the COVID-19 pandemic suggests that taking shielding measures during winter months (e.g., wearing face masks, reducing social contact, regular handwashing) may have the potential to reduce the risk of exacerbations among those with COPD.[1]​ See Secondary prevention.

The table that follows summarizes recommendations on primary prevention of COPD taken from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines.[1]

Note that an individual patient may fall into more than one group, and so interventions might be additive; please review all population and sub-population groups to assess all that apply.

Adults with COPD

All

Intervention
Goal
Intervention

Guideline-directed management of COPD with pharmacologic and non-pharmacologic interventions; vaccinations in line with national guidance

A stepwise approach to inhaled pharmacotherapy is recommended, based on symptoms and exacerbations. Treatment is highly individualized. See:  Chronic obstructive pulmonary disease. 

Consider the use of a personalized written action plan targeted towards reducing the risk of exacerbations, which includes advice on:

  • avoidance of aggravating factors

  • how to monitor/manage worsening of symptoms

  • who to contact in the event of an exacerbation.

Encouragement of physical activity is recommended for all people with COPD, with consideration of referral for pulmonary rehabilitation in those with severe COPD (see ‘With a high symptom burden and high risk of exacerbations’).

For all people with COPD, follow appropriate national guidance on vaccination.

The following are recommended for all adults (and are especially important for those with COPD):

  • Yearly influenza vaccination

  • Vaccination against SARS-CoV-2 infection (COVID-19) in line with national recommendations.

Goal

Reduced symptoms and reduced risk of exacerbation

This overall goal incorporates:

  • relief of symptoms

  • improvement of exercise tolerance

  • improvement of health status

  • prevention of disease progression

  • prevention and treatment of exacerbations

  • reduction of mortality.

Following treatment initiation, reassess for attainment of treatment goals and identification of any barriers to treatment on an ongoing basis.

The following management cycle is recommended on an ongoing basis to guide necessary adjustments to treatment:

  • Review

    • symptoms

    • dyspnea

    • exacerbations.

  • Assess

    • inhaler technique and adherence

    • non-pharmacologic approaches (including pulmonary rehabilitation and self-management education).

  • Adjust

    • escalate, switch inhaler device or molecules, or de-escalate, as appropriate.

With cigarette smoking

Intervention
Goal
Intervention

Pharmacologic +/- non-pharmacologic interventions for smoking cessation

It is recommended that all people with COPD who smoke are strongly encouraged and supported to quit.

Approximately 40% of people with COPD currently smoke cigarettes; continuing smoking has a negative impact on prognosis and progression of the disease.

For people who smoke who have COPD, quitting may be more challenging than for those without COPD who smoke due to greater nicotine dependance, lower self-efficacy and lower self-esteem. Intensive time and resources directed towards smoking cessation may therefore be required.

Brief (3-minute) smoking cessation counseling is effective and is recommended at each point of contact with a health care provider.

Where possible, refer patients who want to quit smoking to a comprehensive smoking cessation program incorporating behavior change techniques, patient education, and pharmacologic and nonpharmacologic interventions.

Tobacco dependance is a chronic condition warranting repeated treatment until long-term or permanent abstinence is achieved. It is important to recognize that relapse is common and reflects the chronic nature of dependence and addiction, and does not represent failure on the part of the patient or clinician.

There is no evidence to support the effectiveness and safety of e-cigarettes as a smoking cessation aid at present.

See: Smoking cessation.

Goal

Smoking abstinence; improvement in daily COPD symptoms and decreased frequency of exacerbations

It is recommended that healthcare providers encourage patients to quit at each clinical encounter.

With less than optimal inhaler technique identified

Intervention
Goal
Intervention

Education, training, and assessment of inhaler device techniques; consider change of device

Most of the drugs used to treat COPD are inhaled; appropriate use of inhaler devices is crucial to optimize treatment. On average, more than two thirds of patients make at least one error in using an inhaler.

It is recommended that the choice of device is tailored to the individual and will depend on access, cost, prescriber, and, most importantly, patient ability and preference. Shared decision making is recommended when choosing a device.

  • Dry powder inhalers are appropriate only if the patient can make a forceful and deep inhalation.

    • Check visually that they can inhale forcefully through the device.

    • If there is doubt, assess objectively or choose an alternative device.

  • Metered-dose inhalers and, to a lesser extent, soft mist inhalers require coordination between device triggering and inhalation, and patients need to be able to perform a slow and deep inhalation.

    • Check visually that the patient can inhale slowly and deeply from the device.

    • If there is doubt, consider adding a spacer/valved holding chamber (VHC), or choose an alternative device.

  • For people unable to use a metered-dose inhaler with or without a spacer/VHC, consider offering a soft mist inhaler or dry powder inhaler or a nebulizer.

Patient education on inhaler technique may take the form of physical or video-based demonstration of the proper technique, with live verification that the patient has mastered the technique.

The following videos may be useful:

​​​​

Dry powder inhalers
Dry powder inhalers

A principal pharmacist shows a patient how to use dry powder devices and discusses ways of improving inhaler technique.

Soft mist inhaler
Soft mist inhaler

A principal pharmacist shows a patient how to use a soft mist inhaler and discusses ways of improving inhaler technique.

Metered dose inhaler
Metered dose inhaler

A principal pharmacist shows a patient how to use a metered dose inhaler and discusses ways of improving inhaler technique.

Metered dose inhaler plus spacer
Metered dose inhaler plus spacer

A principal pharmacist shows a patient how to use a metered dose inhaler plus a spacer and discusses ways of improving inhaler technique.

Goal

Appropriate use of inhaler devices and reduced risk of exacerbation

This requires:

  • choice of appropriate device

  • patient education on good inhaler technique

  • regular checks of inhaler technique

  • adaptation of education and choice of device, as required.

Provide instructions and demonstrate the proper inhalation technique when prescribing a device to ensure that inhaler technique is adequate.

Recheck at each visit that patients continue to use their inhaler correctly.

With less than optimal adherence to prescribed therapy

Intervention
Goal
Intervention

Consider multicomponent intervention to promote adherence

Evidence and guidance on specific strategies is recommended for this common scenario is limited.

Multicomponent interventions incorporating education, motivational, or behavioral interventions delivered by health professionals may improve adherence.

The following have been suggested as strategies to consider:

  • Patient education/counseling with the aim of promoting a better understanding of the disease and drug therapy.

  • Recommendation of behavioral components that are tailored to the individual barriers to each person (e.g., keeping medications in one place, self-monitoring of symptoms, medication reminders, etc).

  • Involving the patient in establishing an individually tailored treatment plan.

Goal

Reduced risk of exacerbation; reduced mortality risk; increased health-related quality of life

With exposure to household and outdoor air pollution

Intervention
Goal
Intervention

Advice on reducing pollution exposure

Wood, animal dung, crop residues, and coal, typically burned in open fires or poorly functioning stoves, may lead to very high levels of household air pollution.

Advise the patient to:

  • ensure efficient ventilation

  • use non-polluting cooking stoves.

Goal

Reduced exposure to household and outdoor air pollution and reduced risk of exacerbation

With occupational exposure to potential irritants

Intervention
Goal
Intervention

Advice on reducing pollution exposure

Although supporting evidence is lacking, it seems logical to advise patients to avoid ongoing exposures to potential irritants (e.g., dust, fumes, and gasses) if possible.

Goal

Reduced occupational exposure to potential irritants and reduced risk of exacerbation

At risk of pneumococcal infection

Intervention
Goal
Intervention

Pneumococcal vaccination

The pneumococcal vaccine is recommended by the CDC for certain patient groups (including those with COPD); check your local immunization schedule.

Goal

Reduced risk of COPD exacerbation and community-acquired pneumonia

At risk of pertussis, tetanus, and diphtheria

Intervention
Goal
Intervention

Vaccination against tetanus, diphtheria, and pertussis

Vaccination against pertussis, tetanus, and diphtheria is recommended for all adults who were not vaccinated in adolescence, and is especially important for those with COPD; check your local immunization schedule.

Goal

Reduced risk of pertussis, tetanus, and diphtheria

At risk of shingles

Intervention
Goal
Intervention

Zoster vaccination

Zoster vaccine is recommended to protect against shingles for some adults and is especially important for those with COPD; check your local immunization schedule.

Goal

Reduced risk of shingles

At risk of respiratory syncytial virus (RSV) infection

Intervention
Goal
Intervention

RSV vaccination

The RSV vaccine is recommended by the CDC for certain patient groups (including those with COPD); check your local immunization schedule.

Goal

Reduced risk of RSV

With a high symptom burden and high risk of exacerbations

Intervention
Goal
Intervention

Consider referral to pulmonary rehabilitation

Referral for a formal pulmonary program is recommended for those at high symptom burden and risk of exacerbations as evidenced by either:

  • a history of ≥ two exacerbations or ≥ one leading to hospitalization (note that this indication is included for completeness but covers secondary rather than primary prevention), or

  • with a modified medical research council dyspnea scale (mMRC) ≥2 and/or COPD assessment test (CAT) ≥10 (i.e., the GOLD guideline’s “ABE” approach, which can be found in the GOLD guidelines).

Programs may encompass the following:

  • Exercise training

  • Education

  • Self-management intervention aiming at behavior change.

Goal

Improved physical and psychological health, promotion of long-term adherence to health-enhancing behaviors and reduced risk of exacerbation

Optimum benefits are seen from programs lasting 6 to 8 weeks.

Supervised exercise training at least twice weekly is recommended.

During times of high COVID-19 prevalence

Intervention
Goal
Intervention

Advise use of basic infection control measures

During times of high prevalence of COVID-19 in the community, advise people with COPD to:

  • maintain social distance

  • regularly wash their hands.

Evidence on the use of facial coverings to prevent COVID-19 in the person wearing the covering is still unclear; however their use at times of high COVID-19 prevalence is typically recommended for those with COPD, providing the person is able to tolerate wearing a mask.

Shielding, which involves minimizing all interactions between individuals at high risk of severe illness from COVID-19 and others, may be recommended for some people with severe COPD.

Goal

Reduced risk of COVID-19 infection and reduced risk of COPD exacerbation

Secondary prevention

Pharmacotherapy

  • Once the patient has stabilized following treatment for an exacerbation, the patient’s maintenance medications should be reviewed, and consideration given to adjusting the medications following exacerbations. The goal should be to reduce the risk and/or severity of future episodes, as well as the use of medications according to evidence-based guidelines.[1][85]

  • The eosinophil count may become a useful indicator of likelihood of benefit from inhaled corticosteroids once the exacerbation has been stabilized.[1] The balance of risks and benefits of corticosteroids for people with milder exacerbations is uncertain. At the moment there is no consensus owing to a lack of peer reviewed data. For patients with one exacerbation per year, a peripheral blood count ≥300 eosinophils/microliter may identify those who are more likely to respond to inhaled corticosteroids in combination with a long-acting beta-2 agonist.[1] For patients with two or more exacerbations per year, or at least one exacerbation severe enough to require hospitalization, inhaled corticosteroids in combination with with a long-acting beta-2 agonist can be considered at blood eosinophil counts ≥100 cells/microliter. However these thresholds should be regarded as estimates, rather than precise cut-off values that can predict different probabilities of treatment benefit.[1]

  • One meta-analysis has shown that vitamin D supplementation reduced the rate of moderate/severe COPD exacerbations in patients with baseline 25-hydroxyvitamin D levels (<25 nmol/L [<10 ng/ml]) but not in those with higher levels.[135] International guidelines from the Global Initiative for Chronic Obstructive Lung Disease therefore recommend that vitamin D levels be measured for patients hospitalized for exacerbations of COPD, and supplements provided for those with severe deficiency (vitamin D levels <25 nmol/L [<10 ng/ml]).[1]

  • Low levels of immunoglobulins have been associat​ed with an increased risk of COPD exacerbation in patients with recurrent COPD exacerbations.[126][127][128]​​​ Low immunoglobulin levels are also associated with increased 1 year mortality.[136]​ Treatment of hypogammaglobulinemia should be considered in these patients in order to reduce the risk of recurrent exacerbations. 

Pulmonary rehabilitation and disease-management programs

  • Patients nonadherent with their medication regimens may develop worsening of signs and symptoms associated with COPD. It is important to discuss and determine adherence with medications in patients presenting with acute exacerbations.[278] Failure to adhere to prescribed medications may be associated with increased healthcare costs.[279] Moreover, healthcare providers do not always adhere to existing guidelines for management of stable COPD or acute COPD exacerbations.[280] This, in turn, may impact COPD exacerbation outcomes. Insufficient peak inspiratory flow rate can lead to suboptimal efficacy of inhaled medications. Consideration should be given to measurement of peak inspiratory flow rate during outpatient clinic visits to see if flow rates are adequate to entrain the patients’ current maintenance bronchodilator, or whether substitution of alternate agents may be needed.[281]

  • Also, patients with COPD are less physically active than healthy adults and low physical activity levels are associated with a faster rate of decline in lung function and increased hospitalizations for COPD exacerbations over time.[270][282][283] Pulmonary rehabilitation programs provide exercise reconditioning and education focused on health-enhancing behaviors that can improve patients’ physical activity levels and knowledge regarding management of their disease.[234][284] As such, patients’ participation in pulmonary rehabilitation programs can play an important role in prevention of subsequent exacerbations, particularly when undertaken within a month following an exacerbation.[85][241][270][278][285] Participation in pulmonary rehabilitation within 90 days of discharge following hospitalization for COPD exacerbation is associated with a significant decrease in mortality risk.[232]

  • Outpatient follow-up of patients within 30 days of hospital discharge following acute exacerbations also helps prevent readmissions and relapse of disease.[274] Action plans can help patients recognize worsening symptoms, initiate earlier treatment, and reduce overall impact of exacerbations.[85][286] [ Cochrane Clinical Answers logo ] ​​​ Enrollment of patients in disease-management and integrated care programs can also be effective in reducing emergency visits and/or hospitalizations for COPD exacerbations.[233][248][249] However, their use remains somewhat controversial given that some trials have not shown any increase in time to hospital readmission.[287] One randomized controlled trial had to be stopped early due to a noted increase in mortality in the patient group randomized to comprehensive care management compared with the control group receiving guideline-based routine clinical care.[98][251] Self-management programs offered immediately after acute exacerbations are associated with positive effects on patients’ knowledge, but based on existing evidence it is not possible to draw firm conclusions regarding their efficacy for other outcomes.[288] Education with management that includes direct access to a healthcare specialist at least monthly is recommended by evidence-based guidelines for patients with previous or recent exacerbations to reduce subsequent severe exacerbations requiring hospitalization.[85] The benefits of disease management programs likely vary depending on program content and structure, the healthcare system in which they are implemented, and the patient population being studied. The role of hospital-at-home programs in the management of COPD exacerbations is being studied.[98][253]

  • Tele-health has been used for home-based disease monitoring and management intervention.[289] Randomized controlled trials have suggested that the use of nurse-centered tele-assistance may decrease the occurrence of exacerbations of COPD, urgent care visits, and hospitalization.[289] The use of such programs may be cost-saving.[254] Other analyses have suggested that home tele-monitoring may prolong the time free of hospitalizations or emergency department visits, but the total number of hospitalizations may not be affected and another randomized controlled trial showed no clear beneficial effects.[98][255] A video tele-health pulmonary rehabilitation intervention, given early after hospitalization for COPD exacerbation, was associated with significantly lower 30-day, all-cause re-admission rates.[290] Heterogeneity of existing studies precludes development of any firm generalizable conclusions regarding the role of tele-health in the prevention or treatment of exacerbations, and as such it is not currently recommended for exacerbation prevention.[1][85][291]

Noninvasive ventilation

  • Evidence suggests that continuing noninvasive ventilation after hospital discharge (given in addition to home oxygen therapy) may reduce mortality and hospital readmissions risk in patients with persistent severe resting hypercapnia following a COPD exacerbation associated with acute respiratory failure.[292]

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