Chronic obstructive pulmonary disease (COPD) flare-ups can take a significant toll on patients—medically, financially, and psychologically. Multiple studies have shown that COPD exacerbations are linked to more doctor visits and increased hospital admissions.
The resulting financial toll is high: One 2012 study reported that in the United States, the average COPD-related healthcare expenditure for a person with chronic bronchitis who experienced two or more COPD exacerbations exceeded $6,000 annually.
The impact on daily activities is significant as well. According to a survey reported in Respiratory Medicine, 45 percent of the 1,100 respondents said that during a flare that didn’t require hospitalization, they were still forced to stay in bed or on the couch all day.
And, with an average recovery time of about two weeks (although there is wide variation), individuals who suffer from frequent COPD exacerbations are more likely to become housebound than those who don’t. Also concerning: About one-quarter of patients do not respond adequately to initial treatment for a flare, and they experience either a relapse or a second COPD exacerbation that requires additional urgent treatment within 30 days. Ominously, COPD exacerbations often presage a progressive decline in lung function.
But a growing body of research over the past several years suggests that some flares can indeed be prevented. Recently, clinicians and researchers from the American College of Chest Physicians (CHEST) and the Canadian Thoracic Society (CTS) with expertise in COPD were brought together to review the most up-to-date, evidence-based research on promising nonpharmacologic and pharmacologic strategies to prevent COPD flares. The panel issued new recommendations that provide important guidance. Here’s a look at some of the highlights—with a spotlight on steps you can take to reduce the frequency and severity of COPD exacerbations. The guideline is published in its entirety in the April 2015 issue of the journal CHEST.
How to reduce your risk
1. Enroll in pulmonary rehabilitation right away. Pumonary rehabilitation has been proved to improve quality of life, exercise tolerance, and shortness of breath in people with COPD. If you have moderate, severe, or very severe COPD, the new guidelines recommend starting pulmonary rehabilitation within one month of the flare to prevent exacerbations. If more than one month passes, pulmonary rehabilitation is not helpful in preventing rehospitalization.
2. If you smoke, get support to help you quit. Although the evidence for smoking cessation to prevent COPD exacerbations is limited, it is the only evidence-based intervention that improves prognosis. In fact, smokers with mild COPD who produce cough and phlegm achieve substantial symptom reductions in the first year after smoking cessation, with less lung function decline and fewer symptoms upon sustained cessation.
These benefits, along with the overall health benefits associated with quitting, as well as findings that cigarette smoking may be associated with infections such as pneumonia, are why the guideline authors suggest smoking cessation counseling and treatment as part of the overall medical plan to prevent COPD exacerbations. Over-the-counter and prescription smoking cessation medications—along with counseling, in person or via telephone—and behavioral modification are effective and cost-effective.
3. Have a written exacerbation plan, and see a case manager regularly. If you have a recent or even a past history of flares, the guidelines recommend health education in conjunction with a written exacerbation action plan and case management that includes a visit with a COPD specialist at least monthly to prevent severe flares. In-person visits are important. The guidelines suggest that telemonitoring compared with usual care does not prevent COPD exacerbations.
4. Get your pneumococcal vaccination. The joint guidelines suggest administering the 23-valent pneumococcal vaccine, which is effective against 23 types of pneumococcal bacteria. Although there is not enough evidence to prove that the vaccine prevents COPD exacerbations, it’s recommended as a preventive healthcare measure for all people age 65 and older and for adults with underlying medical conditions, such as COPD, that put them at greater risk for serious pneumococcal infection.
Your doctor will consider whether you’ve been vaccinated in the past and what type of vaccine you received when determining how many doses of the 23-valent vaccine you’ll need and when to administer them.
5. Don’t skip your annual flu shot. The Centers for Disease Control and Prevention (CDC) recommends a yearly flu shot as a preventive measure for most adults— especially those with a chronic condition such as COPD. The CHEST-CTS guidelines also note that there is moderate evidence that a yearly flu shot is effective in preventing COPD exacerbations. The benefits of the flu shot, coupled with a low risk of side effects, make getting your flu shot a key recommendation and high priority if you have COPD.
6. Find out if your drug regimen is up-to-date. Several different types and combinations of medications are recommended or suggested for maintenance therapy because they have been shown to prevent and reduce the rate of COPD exacerbations.
These include long-acting muscarinic antagonists (LAMAs), such as tiotropium (Spiriva), aclidinium (Tudorza Pressair), or glycopyrrolate (Robinul); long-acting beta-2 agonists (LABAs), such as salmeterol (Serevent) or formoterol (Foradil); and inhaled LABA-corticosteroid combinations. Each has specific benefits and risks that your doctor can discuss with you.
Several oral medications—again, each with specific benefits and risks—may also be considered for use in some people. For example:
• Long-term use of macrolide antibiotics, such as azithromycin (Zithromax), clarithromycin (Biaxin), or erythromycin (Erythrocin), is suggested as an option for patients who, despite optimal maintenance inhaler therapy, have had one or more moderate or severe flares in the past year.
• Oral or IV systemic corticosteroids, such as prednisone or methylprednisolone (Medrol), are suggested to prevent hospitalization for COPD exacerbations in, but not beyond, the first 30 days after an initial flare.
• For people whose COPD is stable but who continue to have periodic exacerbations, oral slow-release theophylline such as Uniphyl, Theo-24, or Quibron-T/SR twice daily may reduce the number of exacerbations.
• For individuals with moderate to severe COPD with chronic bronchitis and a history of at least one flare in the previous year, roflumilast (Daliresp) has been shown to reduce the frequency of exacerbations.
• For people with moderate to severe COPD and chronic bronchitis and a history of two or more flares in the last two years related to thick secretions, treatment with oral N-acetylcysteine (Mucomyst) can help loosen the secretions and may help prevent acute flares.
Keep in mind that not every recommendation is appropriate for every person experiencing COPD exacerbations and that all medications can have adverse effects. For example, the development of antibiotic resistance and hearing loss are some of the concerns associated with long-term macrolide antibiotic use. You’ll need to work with your doctor to find a regimen that works for you and whose benefits outweigh the risks.