Prevention and Management of COPD Exacerbations

Publication Date: March 1, 2017
Last Updated: May 24, 2022

Key Points

Key Points

Prevention and management of exacerbations are key objectives in chronic obstructive pulmonary disease (COPD) management.

Exacerbations are defined clinically as episodes of increasing respiratory symptoms, particularly dyspnea, cough and sputum production, and increased sputum purulence.

Patients with recurrent hospitalizations for exacerbations experience greater impairment in health status and have reduced survival.

Treatments that effectively reduce the frequency and/or severity of exacerbations may have an impact on quality of life, the progression and ultimately the prognosis of COPD.

Treatment

Treatment

For ambulatory patients with an exacerbation of COPD, the Task Force suggests a short course (≤14 days) of oral corticosteroids (C, VL)
620
For ambulatory patients with an exacerbation of COPD, the Task Force suggests the administration of antibiotics. Antibiotic selection should be based upon local sensitivity patterns. (C, M)
620
For patients who are hospitalized with a COPD exacerbation, the Task Force suggests the administration of oral corticosteroids rather than intravenous corticosteroids if gastrointestinal access and function are intact. (C, L)
620
For hospitalized patients with acute or acute-on-chronic hypercapnic respiratory failure due to a COPD exacerbation, the Task Force recommends the use of noninvasive mechanical ventilation. (S, L)
620
For patients with a COPD exacerbation who present to the emergency department or hospital, the Task Force suggests a home-based management program (hospital-at-home) (C, M)
620
For patients who are hospitalized with a COPD exacerbation, the Task Force suggests the initiation of pulmonary rehabilitation within 3 weeks after hospital discharge. (C, VL)
620
For patients who are hospitalized with a COPD exacerbation, the Task Force suggests NOT initiating pulmonary rehabilitation during hospitalization. (C, VL)
620

Prevention

Prevention

For patients who have COPD with moderate or severe airflow obstruction and exacerbations despite optimal inhaled therapy, the Task Force suggests treatment with an oral mucolytic agent to prevent future exacerbations. (C, L)
  • Moderate or severe airflow obstruction is defined as a post-bronchodilator FEV1/FVC <0.70 and an FEV % 1pred of 30–79%.
  • The beneficial effect of mucolytic therapy on the rate of COPD exacerbations was driven by trials that administered high-dose mucolytic therapy (e.g. N-acetylcysteine 600 mg twice daily).
620
In patients who have COPD with moderate or severe airflow obstruction and a history of one or more COPD exacerbations during the previous year, the Task Force recommends that a long-acting muscarinic antagonist (LAMA) be prescribed in preference to long-acting β-agonist (LABA) monotherapy to prevent future exacerbations. (S, M)
  • Moderate or severe airflow obstruction is defined as a post-bronchodilator FEV1/FVC <0.70 and an FEV1% pred of 30–79%.
620
In patients who have COPD with severe or very severe airflow obstruction, symptoms of chronic bronchitis and exacerbations despite optimal inhaled therapy, the Task Force suggests treatment with roflumilast to prevent future exacerbations. (C, M)
Severe or very severe airflow obstruction is defined as a post-bronchodilator FEV1/FVC <0.70 and an FEV% 1pred of <50%.
620
Fluoroquinolone therapy is NOT suggested as treatment for the sole purpose of preventing future COPD exacerbations. (C, M)
620
For patients who have COPD with moderate to very severe airflow obstruction and exacerbations despite optimal inhaled therapy, the Task Force suggests treatment with a macrolide antibiotic to prevent future exacerbations. (C, L)
  • Moderate to very severe airflow obstruction is defined as a post-bronchodilator FEV1/FVC <0.70 and an FEV1% pred of <80%.
  • Before prescribing macrolides, clinicians need to carefully consider patients’ cardiovascular risk factors, particularly for ventricular arrhythmias. There are no data for efficacy and safety beyond 1 year of treatment.
620

Recommendation Grading

Abbreviations

  • ATS: American Thoracic Society
  • COPD: Chronic Obstructive Pulmonary Disease
  • ERS: European Respiratory Society
  • FEV1/FVC: Ratio Of Forced Expiratory Volume In 1 Second To Forced Vital Capacity
  • LABA: Long Acting β 2 Agonist
  • LAMA: Long-acting Muscarinic Antagonist
  • pred: Predicted

Source Citation

Wedzicha JA, Calverley PMA, Albert RK, et al. Prevention of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir. J. 2017; 50:1602265.

Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017; 49:1600791.

The guidelines were a cooperative effort among the American Thoracic Society and the European Respiratory Society.

Disclaimer

This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.

Codes

CPT Codes

Code Descriptor
94680 Oxygen uptake
94004 Ventilation assist and management
94005 Home ventilator management care plan oversight of a patient (patient not present) in home
94681 Oxygen uptake
94662 Continuous negative pressure ventilation (CNP)
94690 Oxygen uptake
94002 Ventilation assist and management
94645 Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition to code for primary procedure)
94664 Demonstration and/or evaluation of patient utilization of an aerosol generator
94644 Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour
94003 Ventilation assist and management
94150 Vital capacity
94060 Bronchodilation responsiveness
94200 Maximum breathing capacity
94250 Expired gas collection
94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator
94660 Continuous positive airway pressure ventilation (CPAP)
94375 Respiratory flow volume loop
94070 Bronchospasm provocation evaluation

ICD-10 Codes

Code Descriptor Documentation Concepts Quality/Performance
Z72.0 Tobacco use
J47.0 Bronchiectasis with acute lower respiratory infection Severity, Temporal parameters, Complication, Contributing factors HCC112, RXHCC226
J44.9 Chronic obstructive pulmonary disease, unspecified Severity, Temporal parameters, Complication, Contributing factors HCC111,, RXHCC226
J47.1 Bronchiectasis with (acute) exacerbation Severity, Temporal parameters, Complication, Contributing factors HCC112, RXHCC226

ICD-10 Complexities

Code Descriptor
P96.81 Exposure to (parental) (environmental) tobacco smoke in the perinatal period
Z87.891 Personal history of nicotine dependence
F17.200 Nicotine dependence, unspecified, uncomplicated