costeroids for COPD exacerbations, as well as to
differentiate the optimal dosage and nebulized corticosteroid choice. Further work is also needed to
assess the potential benefit of combination inhaled
and systemic corticosteroids, a poorly understood
but often used approach to the treatment of exacerbated COPD.
While the topic of this article is the management of exacerbations of COPD, the appropriate
approach to management should also include
addressing measures aimed at preventing subsequent episodes (Table 6). As delineated above,
prior exacerbations are the greatest risk factor for
subsequent exacerbations. 10 Therefore, the routine management of exacerbations should include
optimization of factors associated with recurrent
episodes to prevent relapse.
Despite being among the most effective interventions for stabilization of lung function in COPD,
tobacco cessation remains one of the most difficult
therapies for tobacco-addicted patients to utilize.
Sustained tobacco cessation is associated with
significant decreases in respiratory symptoms and
hospital admissions.124 Nevertheless, this remains
difficult to accomplish. Physicians should take every
opportunity to assess cessation readiness in patients
who still smoke and encourage them to engage in
mechanisms designed at aiding with cessation. 1
Comorbidity modulation may serve as an im-
portant pathway to mitigating risk of subsequent
exacerbation. As described previously, GERD fre-
quently complicates COPD.49 While treatment of
this condition has not clearly been associated with
decreased exacerbation frequency, this should
be addressed as part of the patient’s global care.
Additionally, many patients with GERD are at risk
for aspiration events. In patients with coughing,
choking, or gagging at meal times, screening for
aspiration may enable education regarding bio-
feedback techniques or safer dietary habits to pre-
vent aspiration-related lung damage. Obstructive
sleep apnea frequently complicates COPD as well.
Screening and treatment for this condition is asso-
ciated with decreased frequency of exacerbation.48
Vaccinations also serve as a potential interven-
tion to decrease frequency of exacerbations and
prevent hospitalizations in patients with COPD.
Among 1323 Spanish patients with COPD, those
vaccinated against influenza were significantly
less likely to require hospitalization for exacerba-
tion than those who remained unvaccinated.125 In
another study, 125 patients with COPD were ran-
domized to receive influenza vaccine or placebo.
The incidence of influenza-related acute respira-
tory infection was 28.1 per 100 person-years in the
placebo group and 6. 8 per 100 person-years in the
vaccine group.126 Thus, this represents an interven-
tion with potentially significant benefits for patients
with obstructive lung disease. Importantly, in the
Spanish series, only 55% of patients had received
influenza vaccines. Therefore, it is incumbent upon
physicians to emphasize the importance of this in-
tervention to patients with COPD, particularly those
with a history of exacerbations.
Table 6. Prevention of Exacerbation
Ability (mechanical skill to utilize inhaler devices)
Encourage smoking cessation for patients who still smoke
Provide appropriate vaccines