Preventing Acute Exacerbation in COPD: An Evidence-Based Approach
October 16, 2014
By: Daniel R. Ouellette MD, FCCP
One of the first patients who I saw in my clinic 30 years ago as a first-year internal medicine resident had COPD. An old man, he lived alone in a small home in the desert outside of El Paso, Texas. I treated him with albuterol inhalers, oral theophylline, and domiciliary oxygen. My mentors taught me to treat him for his bronchitic exacerbations with oral corticosteroids and antibiotics and to administer the influenza vaccine yearly in order to prevent him from being hospitalized. This prevention plan seemed to work anecdotally for my patients. However, I was able to find little evidence in the medical literature at that time demonstrating improved clinical outcomes from this prevention strategy. I would have been surprised to hear of a government directive concerning the management of my COPD patients and shocked to see a television advertisement concerning their treatment.
Since then, an augmented array of pharmaceutical agents and medical strategies has emerged for treating and preventing COPD exacerbations and reducing hospitalization rates. Prospective trials and meta-analyses demonstrated benefit from agents historically used to treat COPD exacerbations, such as oral corticosteroids and antibiotics. The use of inhaled corticosteroids was analogously extended by pulmonologists from asthma to COPD. This practice became increasingly supported by clinical trial data demonstrating reduced exacerbation rates, improved respiratory physiology, or both. New agents, such as short- and long-acting inhaled anticholinergics and long-acting inhaled beta agonists, became available. Older agents, such as theophylline, fell out of favor because of a narrow therapeutic window and a belief that the treatment afforded only modest efficacy.
Today, COPD is known to be the third-leading cause of death in America 
. Nearly 24 million Americans may have COPD. Once thought to be a disease of men, COPD claimed the lives of 70,000 women in 2010 as opposed to 64,000 men. The burden on the US health-care system from COPD is enormous, with 715,000 hospital discharges in 2010 and a staggering total health-care cost of 49.9 billion dollars . In an effort to reduce health-care spending, new Medicare rules in 2014 have created penalties for hospitals targeting 30-day readmissions for COPD. Once a strange acronym relegated to the physicians’ lingua-franca, COPD is now on the tip of the tongue of hospital administrators, politicians, and health-care strategists.
CHEST stands ready to help physicians confront the challenges of COPD in the years to come. Central to this effort will be the effective, evidence-based treatment and prevention of acute exacerbations of COPD. With this in mind, experts in COPD and evidence-based medicine from CHEST and the Canadian Thoracic Society have issued a clinical practice guideline Prevention of Acute Exacerbations of COPD. Recommendations are graded in accordance with the strength of the supporting evidence and take into account physician and patient preferences. Text and evidence tables provide information concerning supporting data for the thoughtful physician. Topics covered include pharmacologic treatments, nonpharmacologic treatments, and management strategies. Easy online access makes this guideline a useful, daily tool for the busy CHEST clinician.
Prevention of Acute Exacerbations of COPD: CHEST Guideline is available in the October 16, 2014, Online First edition of the journal CHEST.
Dr. Daniel R. Ouellette has been a clinician, teacher, and researcher in pulmonary and critical care medicine for 25 years. He is currently a Senior Staff Physician at Henry Ford Hospital in Detroit where he chairs the Credentials Committee for the Pulmonary and Critical Care Fellowship Program. He is also an Associate Professor of Medicine at the Wayne State University School of Medicine, the Medical Director of the Respiratory Therapy program at Oakland Community College, and is the Chair of the Guideline Oversight Committee for the American College of Chest Physicians. Dr. Ouellette has over 20 years of military service and was the Consultant to the US Army Surgeon General for Pulmonary Medicine during the last several years of his military career.