What are the most effective ways to reduce the incidence of acute exacerbations of chronic obstructive pulmonary disease (COPD)?
•COPD is a smoking-related lung disease characterized by progressive airflow limitation that leads to cough, breathlessness, and excess sputum production. The natural course of COPD includes episodic exacerbations, defined as an acute change in the patient’s baseline dyspnea, cough, or sputum that is beyond normal daily variation and may require a change in the patient’s regular medications.1,2 Acute exacerbations of COPD have a negative effect on lung function, health-related quality of life, morbidity, and mortality.3,4 Hence, health care providers should strive to implement practices and therapies aimed at preventing acute exacerbations of COPD.
Several nonpharmacological therapies have been shown to decrease the incidence of exacerbations.5 Because viral and bacterial infections are frequent triggers of COPD exacerbations, influenza and pneumococcal vaccinations are routinely recommended for patients with COPD. Studies have demonstrated the ability of these vaccinations to reduce the number and severity of the exacerbations.6,7 For COPD patients with hypoxemia, long-term oxygen therapy has been shown to reduce hospital admission rates.8
Office-based interventions such as education about proper inhaler use and assessment of family and community support structures can increase adherence to medical regimens, thereby reducing exacerbations. Referral for pulmonary rehabilitation after an acute exacerbation can improve health-related quality of life and reduce rates of rehospitalization. While studies have not specifically addressed the effect of smoking cessation on the incidence of acute exacerbations, continued counseling about the importance of smoking cessation should be conducted.
Available inhaled pharmacological therapies for stable COPD include short-acting bronchodilators, long-acting β-agonists (LABAs), long-acting anticholinergics, and corticosteroids. While limited data show that short-acting β-agonists reduce COPD exacerbation rates, several clinical trials have shown that LABAs (salmeterol, formoterol) reduce exacerbations.9,10 Long-acting anticholinergics (tiotropium) have also been shown to effectively reduce exacerbations.11,12 Inhaled corticosteroids, while controversial because of the increased pneumonia risk, have demonstrated efficacy in reducing exacerbation rates in some COPD populations. Insufficient data exist to determine which combination of the classes of inhaled medications is most effective at reducing exacerbation rates.
Given the considerable physical and economic burden associated with acute exacerbations of COPD, employing interventions known to reduce the rates of exacerbations can generate marked benefits for patients and society. Simple interventions, such as vaccinations and patient education, can result in a significant reduction in COPD exacerbation rates. While it remains unclear which combination of inhaled medications is best, it is quite clear that each agent alone or in combination can effectively decrease the number of COPD exacerbations.
Until therapies that slow the progressive decline in lung function seen in COPD are discovered, the pharmacological and nonpharmacological therapies discussed above remain the most effective ways to reduce the incidence of acute exacerbations of COPD and improve quality of life and survival.
1. Rabe KF, Hurd S, Anzueto A, et al; Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176:532-555.
2. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper [published correction appears in Eur Respir J. 2006;27:242]. Eur Respir J. 2004;23:932-946.
3. Seemungal TA, Donaldson GC, Paul EA, et al. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1998;157(5 pt 1):1418-1422.
4. Donaldson GC, Seemungal TA, Bhowmik A, Wedzicha JA. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease [published correction appears in Thorax. 2008;63:753]. Thorax. 2002;57:847-852.
5. Wedzicha JA, Seemungal TA. COPD exacerbations: defining their cause and prevention. Lancet. 2007;370:786-796.
6. Nichol KL, Baken L, Nelson A. Relation between influenza vaccination and outpatient visits, hospitalization, and mortality in elderly persons with chronic lung disease. Ann Intern Med. 1999;130:397-403.
7. Alfageme I, Vazquez R, Reyes N, et al. Clinical efficacy of anti-pneumococcal vaccination in patients with COPD. Thorax. 2006;61:189-195.
8. Ringbaek TJ, Viskum K, Lange P. Does long-term oxygen therapy reduce hospitalisation in hypoxaemic chronic obstructive pulmonary disease? Eur Respir J. 2002;20:38-42.
9. Appleton S, Poole P, Smith B, et al. Long-acting beta2-agonists for poorly reversible chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;3:1-84. doi:10.1002/14651858.CD001104.
10. Calverley PM, Anderson JA, Celli B, et al; TORCH Investigators. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med. 2007;356:775-789.
11. Niewoehner DE, Rice K, Cote C, et al. Prevention of exacerbations of chronic obstructive pulmonary disease with tiotropium, a once-daily inhaled anticholinergic bronchodilator: a randomized trial. Ann Intern Med. 2005;143:317-326.
12. Tashkin DP, Celli B, Senn S, et al; UPLIFT Study Investigators. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med. 2008;359:1543-1554.