Clinical Review From Drug and Therapeutics Bulletin

Preventing exacerbations in chronic obstructive pulmonary disease

BMJ 2011; 342 doi: (Published 24 January 2011) Cite this as: BMJ 2011;342:c7207
  1. Drug and Therapeutics Bulletin
  1. 1Drug and Therapeutics Bulletin Editorial Office, London WC1H 9JR, UK
  1. dtb{at}

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are associated with significant morbidity and mortality. Patients with frequent exacerbations have high levels of anxiety and depression, significantly impaired health status and faster disease progression.1 2 Exacerbations are also the most common cause of emergency respiratory admissions to UK hospitals3 and are costly to health services.2 Here we assess whether and how drug and non-drug interventions can help in preventing exacerbations.


COPD is defined by the Global Initiative for Chronic Lung Disease (GOLD) as “a preventable and treatable disease . . . characterised by airflow limitation that is not fully reversible. It is a progressive systemic disease that results in debility over time.”4 Cigarette smoking is the most important causal factor for the development of the disease and smoking cessation is a crucial intervention that can both reduce the rate of decline in lung function and improve survival.5 6 The severity of COPD is defined in terms of the reduction in forced expiratory volume in 1 second (FEV1) relative to that predicted for age, height, and sex. This measure is considered the most significant (but not only) predictor of prognosis in the disease.7 Mild COPD is defined as an FEV1 of 50-79% of predicted, moderate as 30-49%, and severe as below 30%.8

There is no standard definition for an exacerbation. GOLD describes it as “an event in the natural course of the disease characterised by a change in the patient’s baseline dyspnoea, cough, and/or sputum production that is beyond normal day-to-day variation, is acute in onset, and may warrant a change in regular medication.”4 COPD exacerbations develop because of complex interactions between respiratory viruses, airway bacteria, ambient air pollution, and host factors, which then result in an inflammatory cascade. Consequences of …

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