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Exacerbations in Asthma and COPD: A GINA & GOLD Guideline Quiz
Veronica Hackethal, MD
Exacerbations of asthma and COPD have a negative impact on disease process in both conditions. Find out what you know about guideline-recommended mitigation.
Guidelines on management of both asthma and COPD strongly encourage medication adherence and trigger avoidance to reduce risk of disease exacerbation. In COPD, exacerbations are believed to hasten loss of lung function and prevention of exacerbations is now an important outcome measure in studies of new therapeutics in both diseases.
Answers to the 4 questions that follow are based on evidence-based guidelines from the Global Initiative for Asthma and the Global Initiative for Chronic Obstructive Lung Disease.
Answer: C. Influenza vaccination is an unlikely trigger. Asthma exacerbations can occur because of poor adherence to controller medication or exposure to agents that serve as triggers eg, viral respiratory infections, grass pollen/fungal spores, food allergies, outdoor air pollution, seasonal changes, and even springtime thunderstorms that may stir up pollen. Influenza vaccination is an unlikely trigger of asthma exacerbation, but the vaccination is recommended in patients with asthma (esp when severe), to reduce risk for exacerbations associated with influenza infection.
Question 2. Management of asthma exacerbations in the primary care setting may include all of the above except?
Answer: A. Chest Xray is not recommended. In the primary care setting, asthma exacerbations should be managed by assessing severity (dyspnea, pulse and respiratory rates, O2 saturation, lung function), and initiating SABAs, (albuterol) along with O2 therapy. Routine chest Xray is not recommended. Arrange immediate transfer to acute care if exacerbation is severe. Inhaled SABAs, ipratropium bromide, controlled O2, and systemic corticosteroids may be needed during transfer.
Question 3. True or False: Pneumococcal vaccinations are recommended in patients with COPD and in patients with asthma.
Answer: B. False. Patients with asthma and COPD are at increased risk for pneumococcal infection, which may increase the risk of exacerbations in either condition. For COPD patients aged ≥65, either the PCV13 or the PPSV23 pneumococcal vaccines are recommended.1 Only the PPSV23 vaccine is recommended in younger patients with COPD and significant comorbid conditions. For patients with asthma, evidence is insufficient to recommend routine pneumococcal vaccination.2
Question 4. Which of the medications above can be considered in a patient with COPD who continues to have exacerbations despite being treated with LABA/LAMA/ICS triple therapy?
Answer: D. All of the above. In patients with COPD who experience exacerbations despite being on LABA/LAMA/ICS triple therapy, roflumilast may be considered if the patient has an FEV1<50% predicted and chronic bronchitis. Macrolides like azithromycin and erythromycin may also be considered, with best available evidence supporting the use of azithromycin.