Preventing COPD exacerbations: new options for a crucial and growing problem.
Year: 2014
Type: article
Abstract: Your 66 year old patient with chronic obstructive pulmonary disease (COPD) starts her clinic visit by asking: “How can we prevent another year like the last one?” Her disease is spirometrically-moderate (FEV1 64% predicted), but in the past 12 months she had four ER visits and a hospitalization for “breathing problems”, each requiring antibiotics and oral steroids. She feels she never really recovered from the last attack. She asks, “Will I become dependent on oxygen, like my uncle was before he died?” She is faithfully taking her inhalers, a long-acting beta agonist (LABA)/potent inhaled corticosteroid (ICS) combination, and a long-acting muscarinic antagonist (LAMA). You confirm that she still not smoking, and that her immunizations are current. What can you recommend?
In the 21st century, preventing acute exacerbations of COPD (AECOPD) is as crucial a Primary Care goal as controlling hypertension and dyslipidemias. COPD incidence surpassed stroke in 2008, making it the third leading cause of death in the USA 1. COPD is more prevalent in Veterans than in the age-matched general population, and is markedly under-diagnosed 2,3, especially in women 4. Since 2000, more woman than men died of COPD in the USA 5. With significant latency plus frequent progression even after smoking cessation, COPD prevalence will continue to increase for decades.
Recent advances offer tailored therapies for selected COPD patients. This article explains the importance of preventing AECOPD, summarizes risk factors for frequent AECOPD, and outlines approaches to their prevention.
Importance of preventing AECOPD
In a longitudinal study of 101 patients (mean FEV1 42% predicted), AECOPD not requiring hospitalization significantly impaired both lung function and symptoms, with median recovery times of 6 days and 7 days, respectively 6. But even by 35 days, recovery was incomplete in 25% of patients (by spirometry) and in 14% (by symptoms) 6. Frequent AECOPD accelerate declines in FEV1 that can be permanent 7,8. AECOPD warranting hospitalization are even worse. They account for most of the estimated $30 billion in direct health care expenditures for COPD treatment in the USA in 2010 9, and markedly impair quality of life for the following 6–24 months 10–12.
AECOPD requiring hospitalization are surprisingly lethal: recent in-hospital all-cause mortality rates were 5–7% 13,14, and are much greater in those needing mechanical ventilation. This risk persists for survivors; AECOPD requiring hospitalization significantly and independently predict increased all-cause mortality over the next five years (Figs. 1 & 2) 15. The impact of AECOPD on all-cause mortality is generally underappreciated, as the final cause of death is more often cardiovascular disease than respiratory failure 16,17. COPD itself has long been known from Framingham data to be an independent risk for cardiovascular events. Recent studies show a surge in cardiovascular inflammatory mediators early during AECOPD 18, which is blunted in those on anti-inflammatory treatment 19.
Figure 1
Kaplan-Meier survival curves by frequency of exacerbations in patients with COPD: group A, patients with no acute exacerbations of COPD; group B, patients with 1–2 acute exacerbations of COPD requiring hospital management; group C, patients with ...
Figure 2
Kaplan-Meier survival curves by severity of exacerbations in patients with COPD: (1) no acute exacerbations of COPD; (2) patients with acute exacerbations of COPD requiring emergency service visits without admission; (3) patients with acute exacerbations ...
Clearly, it is incredibly crucial to prevent AECOPDs, and especially to break the cycle of frequent episodes as in the patient described above. The impact of AECOPD on prognosis has led to their inclusion in the most recent staging system of the Global Initiative for Obstructive Lung Disease (GOLD) (http://www.goldcopd.org).
Source: PubMed
Authors: Jeffrey L Curtis, Carlos H Martinez
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2299790979