P: Prevent deterioration
Key Recommendations for P: Prevent deterioration | LoE | SoR |
|---|---|---|
| Focus on reducing the risk of exacerbations to prevent deterioration | III-2 | Strong |
| Emphasise smoking cessation as the most important intervention to prevent worsening of COPD | II | Strong |
| Encourage vaccination to reduce risks associated with influenza, pneumococcal and SARS-CoV-2 (COVID-19) infection | I | Strong |
| Consider long-term macrolide antibiotics in people with moderate to severe COPD and frequent exacerbations | I | Weak |
| Consider long-term oxygen therapy (>18 hours) for patients with COPD with resting hypoxaemia | I | Strong |
| Consider long-term non-invasive ventilation in people with stable COPD and hypercapnia to reduce mortality and hospital admissions | I | Weak |
| Mucolytics may reduce exacerbations in patients with COPD | I | Strong |
SoR = Strength of recommendation according to the GRADE system (Andrews 2013, Guyatt 2008)
REDUCING RISK FACTORS for COPD is a priority, and smoking is the most important of these. A systematic review of 47 studies with an average follow-up of 11 years found a significantly higher decline in FEV1 in people who continued to smoke compared to those who ceased (Lee 2010) [evidence level 1]. The annual decline in FEV1 for those who stopped at the beginning of follow-up was 12.4 ml/year (95% CI 10.1 to 14.7) and for those who stopped during the period of follow-up 8.5 ml/year (95% CI 5.6 to 11.4), both less than people who continued to smoke. While there were limitations to the data, the review clearly found that in people who continue to smoke the annual decline in FEV1 is >10 ml/year greater than in people who have never smoked or stopped smoking. Reduction of exposure to occupational dust, fumes and gases and to indoor and outdoor air pollutants is also recommended. Influenza immunisation reduces the risk of exacerbations and death [evidence level I], while long term oxygen therapy reduces mortality [evidence level I].
Avoidance of passive smoking is also recommended to prevent deterioration. In a cohort study exposure to second hand smoke (SHS) was found to be associated with worse clinical outcomes for people with COPD. Living with a smoker was associated with poorer health-related quality of life (HRQoL) (on both St George’s Respiratory Questionnaire (SGRQ) and COPD Assessment Test (CAT) scores) and increased risk of severe exacerbations (OR 1.51, 95% CI 1.04 to 2.17), while SHS exposure in the last week was associated with worse SGRQ and more symptoms (Putcha 2016) [evidence level III-2].
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