Advancing the Science

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July 8, 2020

Defining the evidence: What works to treat COPD exacerbations

By Elizabeth Zimmermann
decorative photo: table top computer image of lungs and blood vessels

Chronic lower respiratory disease, primarily chronic obstructive pulmonary disease (COPD), is the third leading cause of death in the United States, according to the Centers for Disease Control and Prevention. Approximately 16 million Americans are living with COPD, a disease characterized by lung inflammation and difficulty breathing.

People with COPD often – on average more than once a year – experience a worsening of symptoms, called an exacerbation. These exacerbations are often caused by infections, most typically from a virus, says the American Thoracic Society. (Read the society’s patient education on COPD exacerbation).

Connection to COVID-19

People with COPD are at a greater risk of contracting COVID-19, and likely to experience much worse cases than people with healthy lungs.

To help alleviate concerns, the COPD Foundation has a growing information page with expert answers to questions related to COPD.

In addition, the Centers for Disease Control and Prevention have published special guidelines for people at risk of serious illness from COVID-19.

COPD cannot be cured, and if not well-managed, can lead to lowered quality of life, repeat hospitalizations, and increased risk of developing other life-threatening conditions or cancer.  Numerous treatments exist, including several medications and non-medication therapies. However, until now, there has not been complete understanding of which patients would most benefit from which therapies – and if those therapies are even useful.

In two recent publications, Mayo Clinic researchers summarize both the pharmacologic (medication-based) and nonpharmacologic treatments available for use in patients with exacerbation of COPD. They describe the evidence of effectiveness in patients with mild to severe exacerbations.

The research

Led by Claudia, Dobler, M.D., Ph.D., a Mayo Clinic research collaborator and Zhen Wang, Ph.D., associate director, Mayo Clinic Evidence-based Practice Center, the study team scoured key medical databases for randomized controlled clinical trials among people with exacerbation of COPD. After reviewing nearly 10,000 articles, they found 68 trials examining pharmacological therapies among 10,758 participants; and 30 trials looking at the effectiveness of nonpharmacological therapies among 2,643 participants. These studies did not include any conducted in intensive care or chronic ventilator units, or among patients receiving mechanical ventilation at the start of the trial.

"Antibiotics and systemic corticosteroids are effective in adults with mild to severe exacerbation of COPD, as they reduce treatment failure," says Dr. Dobler. "Mild exacerbations are those that can be treated in an outpatient setting, while severe exacerbations require hospitalization."

The study results support the use of shorter duration (3 days to 2 weeks, versus 10 days to 8 weeks) of systemic (tablets or intravenous) corticosteroid treatment, she says.

medical illustration of COPD, with the parts of the lung and diseased areas identified

"They were equally as effective as longer treatments. There was some evidence that inhaled corticosteroids may be a good alternative to systemic corticosteroids, as they had less adverse events but the same effectiveness," continues Dr. Dobler. "It is worth investigating their effectiveness for exacerbations for COPD in large, well-conducted trials."

The team found "insufficient or no evidence" supporting the use of any other types of medication, she says.  

"We did see some evidence that inhaled steroids were less likely to lead to adverse events, than those received orally or intravenously," says Michael Wilson, M.D., a pulmonary and critical care physician at Mayo Clinic, and study co-author. "However, before changing my practice, I’d like to see some large clinical trials comparing the risks and effectiveness of the different types of steroids used for COPD treatment."

The need for more clinical trials was even more apparent when the team looked at nonpharmacological interventions.

"Some non-pharmacologic therapies, especially exercise started early during an episode of exacerbation, may lead to improved physical mobility in hospitalized patients with moderate to severe exacerbation of COPD," says Dr. Dobler.

The joint guidelines of the American Thoracic Society and the European Respiratory Society published in 2017 included a conditional recommendation to not start exercise, e.g. pulmonary rehabilitation, during hospitalization for exacerbation of COPD.

However, Dr. Dobler says the recommendation was conditional due to very low quality evidence.

She continues, "I think it is likely that we will see a change in this recommendation in coming years."

"Non-medication-based therapies are of interest to me and my colleagues," adds Dr. Wilson. "If we can find ways to keep our patients on their feet, exacerbations may be less severe with swifter recovery."

This is in a literal sense, he says, as well as figuratively.

"Several of the nonpharmacologic interventions were designed to improve lung capacity, to make it easier for patients to breathe," continues Dr. Wilson. "Others were related to fitness and general physical mobility."

"One of the worst things about COPD is that reduced lung function can lead to shortness of breath as well as less ability to be physically active.  When patients have an exacerbation," he says, "Their physical activity may come to a standstill. It can become a vicious cycle."

He and his colleagues hope to see more nonpharmacologic trials as well as pharmacologic, so they can confidently introduce more ways to improve quality of life for their patients.

Meanwhile, these two studies provide a place to start.

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This research was supported by the Agency for Healthcare Research and Quality, and the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

Other co-authors of the two studies were:

  • Allison Morrow
  • Bradley Beuschel
  • MagdoleenHassan (Magdoleen) Eltayeb Farah, M.B.B.S.
  • Abdul M. Majzoub, M.D.
  • Bashar Hasan, M.D.
  • Mohamed Seisa, M.D.
  • Lubna Daraz, Ph.D.
  • Larry Prokop
  • M. Hassan Murad, M.D.

The two studies referenced in this story are listed below:


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Tags: Abdul Majzoub, Bashar Hasan, Center for the Science of Health Care Delivery, Claudia Dobler, COPD, Evidence-based Practice Center, Findings, Lubna Daraz, lung disease, M. Hassan Murad, Magdoleen Farah, Mayo Clinic Proceedings, Michael Wilson, Mohamed Seisa, News, pharmacology, pulmonary and critical care medicine, pulmonology, Zhen Wang

Good luck with your studies and hard work. Wishing you, to everyone’s benefit, great success. 🙏

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