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] People with a high burden of symptoms and history of frequent exacerbations (Global Initiative for Chronic Obstructive Lung Disease [GOLD] group D) are at particular risk of future exacerbations and mortality.[1][91] 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
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.[79][80] More severe COPD is associated with both more frequent and more severe exacerbations.[21][92] Smoking cessation can also reduce risk of exacerbations, and smoking cessation, counseling, and treatment is recommended for people with COPD.[81][82]
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.[93][94][95][96] Yearly influenza vaccine is recommended for adults with COPD.[82][97] 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.[82][98][96] 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.[99]
Pneumococcal vaccination with PPSV23 (23-valent pneumococcal polysaccharide vaccine) is recommended for all patients 65 years of age and older. The PPSV23 is also recommended for younger patients with COPD who have significant comorbidities, such as chronic heart or lung disease.[1][82] The Advisory Committee on Immunization Practices (ACIP) recommends pneumococcal vaccination 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: 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, immunocompromising conditions, cerebrospinal fluid leak, or a cochlear implant should also be vaccinated according to this schedule; a minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for these vulnerable groups, to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these patients. Patients who have received PPSV23 previously (but not PCV13) should receive either PCV20 or PCV15 at least 1 year after PPSV23. Adults with previous PCV13 should complete the previously recommended PPSV23 series.[100][101]
The indications and benefits of vaccination against influenza virus, and Streptococcus pneumoniae, should be discussed with the patient.[93][94][102]
Some data suggest that an oral Haemophilus influenzae vaccine may help reduce recurrent exacerbations of chronic bronchitis in selected patients.[103][104][105][106][107] However, one Cochrane review analysis demonstrated that oral H influenzae vaccine did not significantly reduce the number or severity of exacerbations.[108]
The CDC recommends: the Tdap vaccination (dTaP/dTPa) in patients with COPD to protect against pertussis, tetanus, and diphtheria in those who were not vaccinated in adolescence; and Zoster vaccine to protect against shingles for adults with COPD ages ≥50 years.[97]
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]
Please see the BMJ Best Practice topic 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.[109] 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]
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][82]
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.[272] 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]
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.[273] Failure to adhere to prescribed medications may be associated with increased healthcare costs.[274] Moreover, healthcare providers do not always adhere to existing guidelines for management of stable COPD or acute COPD exacerbations.[275] 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.[276]
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.[264][277][278] 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.[279][280] 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.[82][232][264][273][281] Participation in pulmonary rehabilitation within 90 days of discharge following hospitalization for COPD exacerbation is associated with a significant decrease in mortality risk.[223]
Outpatient follow-up of patients within 30 days of hospital discharge following acute exacerbations also helps prevent readmissions and relapse of disease.[282] Action plans can help patients recognize worsening symptoms, initiate earlier treatment, and reduce overall impact of exacerbations.[82][283] [
]
Enrollment of patients in disease-management and integrated care programs can also be effective in reducing emergency visits and/or hospitalizations for COPD exacerbations.[224][239][240] However, their use remains somewhat controversial given that some trials have not shown any increase in time to hospital readmission.[284] 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.[96][242] 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.[285] 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.[82] 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.[96][244]Tele-health has been used for home-based disease monitoring and management intervention.[286] 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.[286] The use of such programs may be cost-saving.[245] Other analyses have suggested that home tele-monitoring may prolong the time free of hospitalizations or ER visits, but the total number of hospitalizations may not be affected and another randomized controlled trial showed no clear beneficial effects.[96][246] 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.[287] 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][82][288]
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