Prevention and Management of COPD Exacerbations
Publication Date: March 1, 2017
Last Updated: May 24, 2022
Key Points
Key Points
Prevention and management of exacerbations are key objectives in chronic obstructive pulmonary disease (COPD) management.
Exacerbations are defined clinically as episodes of increasing respiratory symptoms, particularly dyspnea, cough and sputum production, and increased sputum purulence.
Patients with recurrent hospitalizations for exacerbations experience greater impairment in health status and have reduced survival.
Treatments that effectively reduce the frequency and/or severity of exacerbations may have an impact on quality of life, the progression and ultimately the prognosis of COPD.
Exacerbations are defined clinically as episodes of increasing respiratory symptoms, particularly dyspnea, cough and sputum production, and increased sputum purulence.
Patients with recurrent hospitalizations for exacerbations experience greater impairment in health status and have reduced survival.
Treatments that effectively reduce the frequency and/or severity of exacerbations may have an impact on quality of life, the progression and ultimately the prognosis of COPD.
Treatment
Treatment
For ambulatory patients with an exacerbation of COPD, the Task Force suggests a short course (≤14 days) of oral corticosteroids (C, VL)
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For ambulatory patients with an exacerbation of COPD, the Task Force suggests the administration of antibiotics. Antibiotic selection should be based upon local sensitivity patterns. (C, M)
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For patients who are hospitalized with a COPD exacerbation, the Task Force suggests the administration of oral corticosteroids rather than intravenous corticosteroids if gastrointestinal access and function are intact. (C, L)
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For hospitalized patients with acute or acute-on-chronic hypercapnic respiratory failure due to a COPD exacerbation, the Task Force recommends the use of noninvasive mechanical ventilation. (S, L)
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For patients with a COPD exacerbation who present to the emergency department or hospital, the Task Force suggests a home-based management program (hospital-at-home) (C, M)
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For patients who are hospitalized with a COPD exacerbation, the Task Force suggests the initiation of pulmonary rehabilitation within 3 weeks after hospital discharge. (C, VL)
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For patients who are hospitalized with a COPD exacerbation, the Task Force suggests NOT initiating pulmonary rehabilitation during hospitalization. (C, VL)
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Prevention
Prevention
For patients who have COPD with moderate or severe airflow obstruction and exacerbations despite optimal inhaled therapy, the Task Force suggests treatment with an oral mucolytic agent to prevent future exacerbations. (C, L)
- Moderate or severe airflow obstruction is defined as a post-bronchodilator FEV1/FVC <0.70 and an FEV % 1pred of 30–79%.
- The beneficial effect of mucolytic therapy on the rate of COPD exacerbations was driven by trials that administered high-dose mucolytic therapy (e.g. N-acetylcysteine 600 mg twice daily).
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In patients who have COPD with moderate or severe airflow obstruction and a history of one or more COPD exacerbations during the previous year, the Task Force recommends that a long-acting muscarinic antagonist (LAMA) be prescribed in preference to long-acting β-agonist (LABA) monotherapy to prevent future exacerbations. (S, M)
- Moderate or severe airflow obstruction is defined as a post-bronchodilator FEV1/FVC <0.70 and an FEV1% pred of 30–79%.
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In patients who have COPD with severe or very severe airflow obstruction, symptoms of chronic bronchitis and exacerbations despite optimal inhaled therapy, the Task Force suggests treatment with roflumilast to prevent future exacerbations. (C, M)
Severe or very severe airflow obstruction is defined as a post-bronchodilator FEV1/FVC <0.70 and an FEV% 1pred of <50%.
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Fluoroquinolone therapy is NOT suggested as treatment for the sole purpose of preventing future COPD exacerbations. (C, M)
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For patients who have COPD with moderate to very severe airflow obstruction and exacerbations despite optimal inhaled therapy, the Task Force suggests treatment with a macrolide antibiotic to prevent future exacerbations. (C, L)
- Moderate to very severe airflow obstruction is defined as a post-bronchodilator FEV1/FVC <0.70 and an FEV1% pred of <80%.
- Before prescribing macrolides, clinicians need to carefully consider patients’ cardiovascular risk factors, particularly for ventricular arrhythmias. There are no data for efficacy and safety beyond 1 year of treatment.
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Recommendation Grading
Abbreviations
- ATS: American Thoracic Society
- COPD: Chronic Obstructive Pulmonary Disease
- ERS: European Respiratory Society
- FEV1/FVC: Ratio Of Forced Expiratory Volume In 1 Second To Forced Vital Capacity
- LABA: Long Acting β 2 Agonist
- LAMA: Long-acting Muscarinic Antagonist
- pred: Predicted
Disclaimer
This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.
Codes
CPT Codes
| Code | Descriptor |
|---|---|
| 94680 | Oxygen uptake |
| 94004 | Ventilation assist and management |
| 94005 | Home ventilator management care plan oversight of a patient (patient not present) in home |
| 94681 | Oxygen uptake |
| 94662 | Continuous negative pressure ventilation (CNP) |
| 94690 | Oxygen uptake |
| 94002 | Ventilation assist and management |
| 94645 | Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition to code for primary procedure) |
| 94664 | Demonstration and/or evaluation of patient utilization of an aerosol generator |
| 94644 | Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour |
| 94003 | Ventilation assist and management |
| 94150 | Vital capacity |
| 94060 | Bronchodilation responsiveness |
| 94200 | Maximum breathing capacity |
| 94250 | Expired gas collection |
| 94640 | Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator |
| 94660 | Continuous positive airway pressure ventilation (CPAP) |
| 94375 | Respiratory flow volume loop |
| 94070 | Bronchospasm provocation evaluation |
ICD-10 Codes
| Code | Descriptor | Documentation Concepts | Quality/Performance |
|---|---|---|---|
| Z72.0 | Tobacco use | ||
| J47.0 | Bronchiectasis with acute lower respiratory infection | Severity, Temporal parameters, Complication, Contributing factors | HCC112, RXHCC226 |
| J44.9 | Chronic obstructive pulmonary disease, unspecified | Severity, Temporal parameters, Complication, Contributing factors | HCC111,, RXHCC226 |
| J47.1 | Bronchiectasis with (acute) exacerbation | Severity, Temporal parameters, Complication, Contributing factors | HCC112, RXHCC226 |
ICD-10 Complexities
| Code | Descriptor |
|---|---|
| P96.81 | Exposure to (parental) (environmental) tobacco smoke in the perinatal period |
| Z87.891 | Personal history of nicotine dependence |
| F17.200 | Nicotine dependence, unspecified, uncomplicated |