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.
Treatment
For ambulatory patients with an exacerbation of
COPD, the Task Force suggests a short course (≤14 days) of
oral corticosteroids ( C, VL ) 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 ) 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 ) 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 )
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 )
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 )
For patients who are hospitalized with a COPD exacerbation, the Task Force suggests NOT initiating pulmonary rehabilitation during hospitalization. ( C, VL )
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 % pred 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).
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%.
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% pred of <50%.
Fluoroquinolone therapy is NOT suggested as treatment for the sole purpose of preventing future
COPD exacerbations.
( C, M ) 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.
Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations
Source: Grading of Recommendations Assessment, Development and Evaluation Working Group (Schunemann HJ et al. Am J Respir Crit Care Med. 2006;174:605-14. Guyatt GH et al. BMJ 2008;336:924-6).
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
Source Citation
Wedzicha JA, Calverley PMA, Albert RK, et al. Prevention of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir. J. 2017; 50:1602265.
Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017; 49:1600791.
The guidelines were a cooperative effort among the American Thoracic Society and the European Respiratory Society.
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.
