Chest
Volume 147, Issue 4, April 2015, Pages 894-942
Journal home page for Chest

Evidence-Based Medicine
Prevention of Acute Exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline

https://doi.org/10.1378/chest.14-1676Get rights and content

BACKGROUND:COPD is a major cause of morbidity and mortality in the United States as well as throughout the rest of the world. An exacerbation of COPD (periodic escalations of symptoms of cough, dyspnea, and sputum production) is a major contributor to worsening lung function, impairment in quality of life, need for urgent care or hospitalization, and cost of care in COPD. Research conducted over the past decade has contributed much to our current understanding of the pathogenesis and treatment of COPD. Additionally, an evolving literature has accumulated about the prevention of acute exacerbations.

METHODS:In recognition of the importance of preventing exacerbations in patients with COPD, the American College of Chest Physicians (CHEST) and Canadian Thoracic Society (CTS) joint evidence-based guideline (AECOPD Guideline) was developed to provide a practical, clinically useful document to describe the current state of knowledge regarding the prevention of acute exacerbations according to major categories of prevention therapies. Three key clinical questions developed using the PICO (population, intervention, comparator, and outcome) format addressed the prevention of acute exacerbations of COPD: nonpharmacologic therapies, inhaled therapies, and oral therapies. We used recognized document evaluation tools to assess and choose the most appropriate studies and to extract meaningful data and grade the level of evidence to support the recommendations in each PICO question in a balanced and unbiased fashion.

RESULTS:The AECOPD Guideline is unique not only for its topic, the prevention of acute exacerbations of COPD, but also for the first-in-kind partnership between two of the largest thoracic societies in North America. The CHEST Guidelines Oversight Committee in partnership with the CTS COPD Clinical Assembly launched this project with the objective that a systematic review and critical evaluation of the published literature by clinical experts and researchers in the field of COPD would lead to a series of recommendations to assist clinicians in their management of the patient with COPD.

CONCLUSIONS:This guideline is unique because it provides an up-to-date, rigorous, evidence-based analysis of current randomized controlled trial data regarding the prevention of COPD exacerbations.

Section snippets

PICO 1: Do Nonpharmacologic Treatments and Vaccinations Prevent/Decrease Acute Exacerbations of COPD?

1. In patients with COPD, we suggest administering the 23-valent pneumococcal vaccine as part of overall medical management but did not find sufficient evidence that pneumococcal vaccination prevents acute exacerbations of COPD(Grade 2C).

Expert Panel Composition

Members from CHEST and CTS were selected to participate on the AECOPD Guideline panel based on their expertise in the field. CTS representatives were members of the CTS COPD Clinical Assembly. Members who were interested in serving on the guideline panel were asked to submit their curriculum vitae, statement of interest, and conflict of interest disclosure form to the CHEST GOC for review. The final panel comprised a chair from CHEST and vice-chair from CTS as well as eight panelists from CHEST

PICO 1: Do Nonpharmacologic Treatments and Vaccinations Prevent/Decrease Acute Exacerbations of COPD?

Effective support and management of individuals at risk for an AECOPD demands a comprehensive and patient-centered approach. The widely adopted Chronic Care Model34, 35 recognizes that improvements in care require approaches incorporating patient-, provider-, and system-level interventions. Key elements of the Chronic Care Model are the health system, delivery system design (including case management), decision support, clinical information systems, self-management support (including

Conclusions

These guidelines provide the clinician with evidence-based information on therapies to prevent COPD exacerbations using an objective, rigorous, evidence-based approach to the assessment of the existing literature regarding nonpharmacologic inhaled and oral therapies (Fig 1). We have avoided providing opinions, instead using objective assessment of each recommendation where the data are robust enough to provide a meaningful conclusion based on the available data. This assessment also highlights

Acknowledgments

Author contributions:G. J. C. is the guarantor of the manuscript. G. J. C. drafted recommendations and supporting text for the Inhaled Therapies section and Introduction, oversaw the drafting of the Inhaled Therapies section and the entire manuscript, and synthesized all of the sections in the final manuscript and executive summary; J. B. oversaw the drafting of the Oral Therapies section and drafted supporting text for the section, advised the nonpharmacologic therapies writing committee, and

References (285)

  • A Furumoto et al.

    Additive effect of pneumococcal vaccine and influenza vaccine on acute exacerbation in patients with chronic lung disease

    Vaccine

    (2008)
  • AS Monto

    Influenza: quantifying morbidity and mortality

    Am J Med

    (1987)
  • CH Howells et al.

    Prophylactic use of influenza vaccine in patients with chronic bronchitis. A pilot trial

    Lancet

    (1961)
  • P Wongsurakiat et al.

    Acute respiratory illness in patients with COPD and the effectiveness of influenza vaccination: a randomized controlled study

    Chest

    (2004)
  • CP Hersh et al.

    Predictors of survival in severe, early onset COPD

    Chest

    (2004)
  • RE Kanner et al.

    Effects of randomized assignment to a smoking cessation intervention and changes in smoking habits on respiratory symptoms in smokers with early chronic obstructive pulmonary disease: the Lung Health Study

    Am J Med

    (1999)
  • D Makris et al.

    Exacerbations and lung function decline in COPD: new insights in current and ex-smokers

    Respir Med

    (2007)
  • D Tashkin et al.

    Smoking cessation in patients with chronic obstructive pulmonary disease: a double-blind, placebo-controlled, randomised trial

    Lancet

    (2001)
  • CA Jiménez-Ruiz et al.

    Smoking characteristics: differences in attitudes and dependence between healthy smokers and smokers with COPD

    Chest

    (2001)
  • E Szabo et al.

    Chemoprevention of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

    Chest

    (2013)
  • AL Ries et al.

    Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines

    Chest

    (2007)
  • Y Lacasse et al.

    Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease

    Lancet

    (1996)
  • M Behnke et al.

    Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease

    Respir Med

    (2000)
  • N Murphy et al.

    Extending a home from hospital care programme for COPD exacerbations to include pulmonary rehabilitation

    Respir Med

    (2005)
  • E Farrero et al.

    Impact of a hospital-based home-care program on the management of COPD patients receiving long-term oxygen therapy

    Chest

    (2001)
  • M Lainscak et al.

    Discharge coordinator intervention prevents hospitalizations in patients with COPD: a randomized controlled trial

    J Am Med Dir Assoc

    (2013)
  • JJ Soler et al.

    Effectiveness of a specific program for patients with chronic obstructive pulmonary disease and frequent exacerbations [in Spanish]

    Arch Bronconeumol

    (2006)
  • F Gallefoss

    The effects of patient education in COPD in a 1-year follow-up randomised, controlled trial

    Patient Educ Couns

    (2004)
  • Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. Updated 2103. Global Initiative for Chronic Obstructive Lung Disease website

  • V Brusasco

    Reducing cholinergic constriction: the major reversible mechanism in COPD

    Eur Respir Rev

    (2006)
  • Chronic obstructive pulmonary disease (COPD). Public Health Agency of Canada website

  • Deaths: final data for 2009

    Natl Vital Stat Rep

    (2012)
  • Centers for Disease Control and Prevention; National Center for Health Statistics . National Health Interview Survey...
  • DM Mannino et al.

    Centers for Disease Control and Prevention. Chronic obstructive pulmonary disease surveillance—United States, 1971-2000

    MMWR Surveill Summ

    (2002)
  • Centers for Disease Control and Prevention; National Center for Health Statistics . National Hospital Discharge Survey...
  • C onfronting COPD in America, 2000 . Silver Spring, MD: Schulman, Ronca and Bucuvalas, Inc (SRBI); 2000. Funded by...
  • AF Connors et al.

    Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments)

    Am J Respir Crit Care Med

    (1996)
  • TA Seemungal et al.

    Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease

    Am J Respir Crit Care Med

    (1998)
  • M Miravitlles et al.

    Clinical outcomes and cost analysis of exacerbations in chronic obstructive pulmonary disease

    Lung

    (2013)
  • EF Wouters

    Economic analysis of the Confronting COPD survey: an overview of results

    Respir Med

    (2004)
  • BR Celli et al.

    ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper

    Eur Respir J

    (2004)
  • A Qaseem et al.

    American College of Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society

    Ann Intern Med

    (2011)
  • RK Albert et al.

    COPD Clinical Research Network. Azithromycin for prevention of exacerbations of COPD

    N Engl J Med

    (2011)
  • DP Tashkin et al.

    UPLIFT Study Investigators. A 4-year trial of tiotropium in chronic obstructive pulmonary disease

    N Engl J Med

    (2008)
  • MC Brouwers et al.

    AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care

    CMAJ

    (2010)
  • R Diekemper et al.

    P154 development of the Documentation And Appraisal Review Tool (DART) for systematic reviews [poster]

    BMJ Qual Saf

    (2013)
  • Higgins JPT , Altman DG , Sterne JAC ; Cochrane Statistical Methods Group ; Cochrane Bias Methods Group. Chapter 8:...
  • SH Downs et al.

    The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions

    J Epidemiol Community Health

    (1998)
  • A Langer-Gould et al.

    Clinical and demographic predictors of long-term disability in patients with relapsing-remitting multiple sclerosis: a systematic review

    Arch Neurol

    (2006)
  • SD Aaron et al.

    Canadian Thoracic Society/Canadian Respiratory Clinical Research Consortium.Counting, analysing and reporting exacerbations of COPD in randomised controlled trials

    Thorax

    (2008)
  • Cited by (216)

    • Evaluation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbation in the Emergency Department

      2022, Emergency Medicine Clinics of North America
      Citation Excerpt :

      Pulmonary rehabilitation for those with COPD can prevent recurrent exacerbation.79

    • Early symptom recognition and symptom management among exacerbation COPD patients: A qualitative study

      2022, Applied Nursing Research
      Citation Excerpt :

      In the moderated level, medication changes must happen. Patients with a severe level of AECOPD must go to the hospital (Criner et al., 2015; GOLD, 2013). Most cases of AECOPD occur at home and induce COPD patients to be admitted in hospitals.

    View all citing articles on Scopus

    DISCLAIMER:American College of Chest Physicians and Canadian Thoracic Society guidelines and other clinical statements are intended for general information only and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/CHEST-Guidelines.FUNDING/SUPPORT:The American College of Chest Physicians and the Canadian Thoracic Society supported the development this article and the innovations addressed within.Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

    View full text