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Evidence-Based Medicine |

Prevention of Acute Exacerbations of COPDCHEST and CTS AECOPD Guideline: American College of Chest Physicians and Canadian Thoracic Society Guideline FREE TO VIEW

Gerard J. Criner, MD, FCCP; Jean Bourbeau, MD, FCCP; Rebecca L. Diekemper, MPH; Daniel R. Ouellette, MD, FCCP; Donna Goodridge, RN, PhD; Paul Hernandez, MDCM; Kristen Curren, MA; Meyer S. Balter, MD, FCCP; Mohit Bhutani, MD, FCCP; Pat G. Camp, PhD, PT; Bartolome R. Celli, MD, FCCP; Gail Dechman, PhD, PT; Mark T. Dransfield, MD; Stanley B. Fiel, MD, FCCP; Marilyn G. Foreman, MD, FCCP; Nicola A. Hanania, MD, FCCP; Belinda K. Ireland, MD; Nathaniel Marchetti, DO, FCCP; Darcy D. Marciniuk, MD, FCCP; Richard A. Mularski, MD, MSHS, MCR, FCCP; Joseph Ornelas, MS; Jeremy D. Road, MD; Michael K. Stickland, PhD
Author and Funding Information

From the Temple University School of Medicine (Dr Criner), Philadelphia, PA; Respiratory Epidemiology and Clinical Research Unit (Dr Bourbeau), Montreal Chest Institute, McGill University Health Centre, Montreal, QC, Canada; American College of Chest Physicians (Ms Diekemper and Mr Ornelas), Glenview, IL; Henry Ford Health System (Dr Ouellette), Detroit, MI; College of Medicine (Dr Goodridge), University of Saskatchewan, Saskatoon, SK, Canada; Department of Medicine (Dr Hernandez), and School of Physiotherapy (Dr Dechman), Dalhousie University, Halifax, NS, Canada; Canadian Thoracic Society (Ms Curren), Ottawa, ON, Canada; Division of Respirology (Dr Balter), University of Toronto, Toronto, ON, Canada; University of Alberta (Dr Bhutani), Edmonton, AB, Canada; Department of Physical Therapy (Dr Camp), University of British Columbia, Vancouver, BC, Canada; Harvard Medical School (Dr Celli), Brigham and Women’s Hospital, Boston, MA; University of Alabama at Birmingham and Birmingham VA Medical Center (Dr Dransfield), Birmingham, AL; Medical Center/Atlantic Health System (Dr Fiel), Morristown, NJ; Morehouse School of Medicine (Dr Foreman), Atlanta, GA; Baylor College of Medicine (Dr Hanania), Houston, TX; TheEvidenceDoc, LLC (Dr Ireland), Pacific, MO; Temple University School of Medicine (Dr Marchetti), Philadelphia, PA; Division of Respirology, Critical Care and Sleep Medicine (Dr Marciniuk), Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada; Kaiser Permanente Center for Health Research (Dr Mularski), Portland, OR; Department of Medicine (Dr Road), University of British Columbia, Vancouver, BC, Canada; and Division of Pulmonary Medicine (Dr Stickland), University of Alberta, Edmonton, AB, Canada.

CORRESPONDENCE TO: Gerard J. Criner, MD, FCCP, Department of Pulmonary and Critical Care Medicine, Temple University School of Medicine, 745 Parkinson Pavilion, 3401 N Broad St, Philadelphia, PA 19140; e-mail: gerard.criner@tuhs.temple.edu


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.


Chest. 2015;147(4):894-942. doi:10.1378/chest.14-1676
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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.

Figures in this Article
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).

Underlying Values and Preferences:

This recommendation places high value on the benefits of pneumococcal vaccine for general health, and we endorse existing guidelines that recommend it for patients with COPD. Although evidence does not specifically support using the vaccine for the prevention of acute exacerbations, multiple bodies, including the US Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO), recommend the use of pneumococcal vaccine for all adults aged ≥ 65 years and in those aged 19 to 64 years with underlying medical conditions such as COPD that put them at greater risk of serious pneumococcal infection.

2. In patients with COPD, we recommend administering the influenza vaccine annually to prevent acute exacerbations of COPD (Grade 1B).

Underlying Values and Preferences:

This recommendation places high value on the benefits of influenza vaccination for general health, the low risk of side effects, and the existing guidelines that recommend it for patients with COPD. Although the effect and evidence are moderate for the prevention of acute exacerbations of COPD, multiple bodies, including the CDC and WHO, recommend the use of a yearly influenza vaccine for all adults, including those with COPD.

3. In patients with COPD, we suggest including smoking cessation counseling and treatment using best practices as a component of a comprehensive clinical strategy to prevent acute exacerbations of COPD (Grade 2C).

Underlying Values and Preferences:

This recommendation places high value on the benefits of smoking cessation for all individuals. In particular, it is the only evidence-based intervention that improves COPD prognosis by mitigating lung function decline and reduces symptoms. Although the effect and evidence for smoking cessation in the prevention of acute exacerbations of COPD are low, evidence supports smoking cessation for many reasons: 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 less symptoms upon sustained cessation; cigarette smoking may be associated with infections such as pneumonia; among other general health benefits. The benefit from smoking cessation outweighs the risks, and a myriad of strategies have been summarized by other guidelines and reviews. In general, effective smoking cessation programs include behavioral, physiologic, and psychologic components comprising an acknowledgment of current smoking followed by advice to quit, pharmacologic therapies (nicotine replacement therapy, antidepressants, nicotine receptor modifier therapy), and counseling (in-person or telephone counseling), with cessation rates ranging from 8.8% to 34.5%. Smoking cessation that includes counseling and pharmacologic interventions are cost-effective.

4. In patients with moderate, severe, or very severe COPD who have had a recent exacerbation (ie, ≤ 4 weeks), we recommend pulmonary rehabilitation to prevent acute exacerbations of COPD (Grade 1C).

Underlying Values and Preferences:

The pulmonary rehabilitation recommendations place high value on pulmonary rehabilitation reducing the risk of hospitalizations in patients with COPD who have had a recent COPD exacerbation (ie, ≤ 4 weeks posthospitalization). Although it has been well established that pulmonary rehabilitation improves quality of life, exercise tolerance, and dyspnea, these recommendations do not support pulmonary rehabilitation for the prevention of rehospitalizations in patients with COPD greater than 4 weeks after a recent hospitalization.

5. In patients with moderate, severe, or very severe COPD who have had an exacerbation greater than the past 4 weeks, we do not suggest pulmonary rehabilitation to prevent acute exacerbations of COPD (Grade 2B).

Underlying Values and Preferences:

The pulmonary rehabilitation recommendations place high value on pulmonary rehabilitation reducing the risk of hospitalizations in patients with COPD who have had a recent COPD exacerbation (ie, ≤ 4 weeks posthospitalization). Although it has been well established that pulmonary rehabilitation improves quality of life, exercise tolerance, and dyspnea, these recommendations do not support pulmonary rehabilitation for the prevention of rehospitalizations in patients with COPD greater than 4 weeks after a recent hospitalization.

6. In patients with COPD, we suggest that education alone should not be used for prevention of acute exacerbations of COPD (Ungraded Consensus-Based Statement).

Underlying Values and Preferences:

This recommendation places high value on reducing hospitalizations for COPD exacerbations, as these are associated with increased morbidity and mortality. A lower value was placed on the motivational educational intervention because it is labor intensive compared with traditional education techniques.

7. In patients with COPD, we suggest that case management alone should not be used for prevention of acute exacerbations of COPD (Ungraded Consensus-Based Statement).

Underlying Values and Preferences:

This recommendation places high value on reducing hospitalizations for COPD exacerbations, as these are associated with increased morbidity and mortality. A lower value was placed on the lack of change in quality of life in either group because this information was present for only a small proportion of the entire sample.

8. In patients with COPD with a previous or recent history of exacerbations, we recommend education and case management that includes direct access to a health-care specialist at least monthly to prevent severe acute exacerbations of COPD, as assessed by decreases in hospitalizations (Grade 1C).

Underlying Values and Preferences:

This recommendation places high value on reducing hospitalizations for COPD exacerbations, as these are associated with increased morbidity and mortality.

9. In patients with moderate to severe COPD, we suggest education together with an action plan but without case management does not prevent severe acute exacerbations of COPD, as assessed by a decrease in ED visits or hospitalizations over a 12-month period (Grade 2C).

Underlying Values and Preferences:

This recommendation places high value on reducing hospitalizations for COPD exacerbations, as these are associated with increased morbidity and mortality.

10. For patients with COPD, we suggest education with a written action plan and case management for the prevention of severe acute exacerbations of COPD, as assessed by a decrease in hospitalizations and ED visits (Grade 2B).

Underlying Values and Preferences:

This recommendation places high value on reducing COPD-related hospitalizations, as these are associated with increased morbidity and mortality. Hospitalizations were believed to best reflect exacerbations because increased physician visits or increased medication use could be a result of the intervention to prevent an exacerbation. High value was also placed on changes in individuals with a history of exacerbations and on outcomes that specifically identified COPD-related hospitalizations. The recommendation reflects the fact that one study reported increased mortality in the intervention group. Although we do not know the reason for increased mortality in this one study, patients with underlying severe disease and clinical instability need close attention and careful follow-up. This point emphasizes that a specially trained staff is required to supervise this intervention and that patient selection must be individualized.

11. For patients with COPD, we suggest that telemonitoring compared with usual care does not prevent acute exacerbations of COPD, as assessed by decreases in emergency room visits, exacerbations, or hospitalizations over a 12-month period (Grade 2C).

Underlying Values and Preferences:

There is insufficient evidence at this time to support the contention that telemonitoring prevents COPD exacerbations.

PICO 2: Does Maintenance Inhaled Therapy Prevent/Decrease Acute Exacerbations of COPD?

12. In patients with moderate to severe COPD, we recommend the use of long-acting β2-agonist compared with placebo to prevent moderate to severe acute exacerbations of COPD (Grade 1B).

Underlying Values and Preferences

This recommendation places high value on long-acting β2-agonist therapy reducing the risk of acute exacerbations of COPD, both moderate (required course of oral steroids, antibiotics, or both) and severe (required hospitalization), together with the comparative benefit of long-acting β2-agonist therapy improving quality of life and lung function compared with placebo. This recommendation also acknowledges that there are no significant differences in serious adverse events or incidence of mortality between long-acting β2-agonist therapy and placebo in this patient group.

13. In patients with moderate to severe COPD, we recommend the use of a long-acting muscarinic antagonist compared with placebo to prevent moderate to severe acute exacerbations of COPD (Grade 1A).

Underlying Values and Preferences: