Impact and prevention of severe exacerbations of COPD: a review of the evidence

Abstract

Severe exacerbations of COPD, ie, those leading to hospitalization, have profound clinical implications for patients and significant economic consequences for society. The prevalence and burden of severe COPD exacerbations remain high, despite recognition of the importance of exacerbation prevention and the availability of new treatment options. Severe COPD exacerbations are associated with high mortality, have negative impact on quality of life, are linked to cardiovascular complications, and are a significant burden on the health-care system. This review identified risk factors that contribute to the development of severe exacerbations, treatment options (bronchodilators, antibiotics, corticosteroids [CSs], oxygen therapy, and ventilator support) to manage severe exacerbations, and strategies to prevent readmission to hospital. Risk factors that are amenable to change have been highlighted. A number of bronchodilators have demonstrated successful reduction in risk of severe exacerbations, including long-acting muscarinic antagonist or long-acting β₂-agonist mono- or combination therapies, in addition to vaccination, mucolytic and antibiotic therapy, and nonpharmacological interventions, such as pulmonary rehabilitation. Recognition of the importance of severe exacerbations is an essential step in improving outcomes for patients with COPD. Evidence-based approaches to prevent and manage severe exacerbations should be implemented as part of targeted strategies for disease management.

Keywords: bronchodilators; hospitalization; long-acting muscarinic antagonist; prevention; severe COPD exacerbations; treatment.

Figure 1

Hazard function of successive hospitalized COPD exacerbations (per 10,000 per day) for a cohort of 73,106 patients from the time of their first ever hospitalization for a COPD exacerbation over the follow-up period, with the time between successive exacerbations estimated using the median inter-exacerbation times as time to the next exacerbation or death, whichever occurs first. Note: Adapted from Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality, Suissa S, Dell’Aniello S, Ernst P, Volume 67, pages 957–963, copyright 2012 with permission from BMJ Publishing Group Ltd.

Figure 2

Emergency room visits and hospitalizations due to COPD exacerbations: Continuing to Confront COPD International Patient Survey. Notes: Adapted with permission of Dove Medical Press Ltd, from Continuing to Confront COPD International Patient Survey: methods, COPD prevalence, and disease burden in 2012–2013, Landis SH, Muellerova H, Mannino DM, et al, Volume 9, Copyright 2006; permission conveyed through Copyright Clearance Center, Inc. Calculated from response to the questions “In the past 12 months, did any of these episodes (worsening of your breathing problems) require an ER visit?” and “In the past 12 months, did any of these episodes (worsening of your breathing problems) require hospitalization?”