Exacerbations and mortality in chronic obstructive pulmonary disease – is it time to shift our treatment goals?


Professor John Hurst, Professor of Respiratory Medicine at University College London and honorary consultant at Royal Free London NHS Foundation Trust

Chronic obstructive pulmonary disease (COPD) is a common, yet neglected disease and our patients deserve better.1 Despite much progress understanding the biology of COPD, there remains a significant unmet need and that is particularly true in the prevention and treatment of exacerbations. There have been limited new medicines to treat an exacerbation in my entire professional life spanning twenty years, and thus effective prevention is paramount.  Exacerbations are associated with poor quality of life2 and excess, premature mortality3,4, therefore, effective prevention of exacerbations is critical for patients too. Questions remain however, about how to best target currently available and novel interventions, especially inhaled corticosteroids, and whether more effective targeting of exacerbation prevention measures will result in the ‘holy grail’ of COPD care: a reduction in mortality.

COPD is the third leading cause of death globally. As a respiratory community, reducing the risk of exacerbations should be a priority for treatment because of their impact on mortality.3-7

Professor John Hurst Professor of Respiratory Medicine at University College London and honorary consultant at Royal Free London NHS Foundation Trust

Reducing the risk of COPD exacerbations

Many COPD patients live with the constant threat of an exacerbation – an acute worsening of symptoms which can lead to permanent loss of lung function8 and increased risk of mortality.3,4 While most patients with COPD will experience exacerbations, they are often not reported by the patient and are therefore left under-treated.9-13

Research has shown that even a single COPD exacerbation may be associated with a significant increase in the rate of decline in lung function,14,15 deterioration in quality of life2, and increase the risk of mortality.3,4 Just one exacerbation can double the rate of lung function decline14,15 and increase the risk of a future hospitalisation by 21%.16 Further, damage from a COPD exacerbation goes beyond just the lungs, with the risk of cardiovascular complications such as myocardial infarction and stroke also increased following a moderate exacerbation.17 Sadly, 1 in 5 patients will die within one year following their first COPD hospitalisation.3 As a respiratory community, reducing the risk of exacerbations should be a priority for treatment because of their impact on mortality.3,4,6,7

An opportunity to transform care in COPD

In addition to prevention of exacerbations, earlier diagnosis, improving lung function, and managing daily symptoms such as breathlessness, are important treatment goals in the management of COPD.1 However, the current global treatment paradigm is one of failure-driven escalation.1

As we continue the fight against COVID-19, the global pandemic has highlighted why we must optimise COPD treatment in order to better reduce a patient’s risk of exacerbations to slow disease progression, keep patients out of hospital and allow people with COPD to live longer and healthier lives.



1. GOLD. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020. [Online]. Available at: http://goldcopd.org. [Last accessed: May 2020].

2. Roche N, Wedzicha JA, Patalano F, et al. COPD exacerbations significantly impact quality of life as measured by SGRQ-C total score: results from the FLAME study. Eur Resp J. 2017; 50 (Suppl 61): OA1487.

3. Ho TW, Tsai YJ, Ruan SY, et al. In-Hospital and One-Year Mortality and Their Predictors in Patients Hospitalized for First-Ever Chronic Obstructive Pulmonary Disease Exacerbations: A Nationwide Population-Based Study. PLOS ONE. 2014; 9 (12): e114866.

4. Suissa S, Dell’Aniello S, Ernst P. Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality. Thorax. 2012; 67 (11): 957-63.

5. Quaderi SA, Hurst JR. The unmet global burden of COPD. Glob Health Epidemiol Genom. 2018; 3: e4. Published 2018 Apr 6. doi:10.1017/gheg.2018.1

6. Lindenauer PK, Dharmarajan K, Qin L, et al. Risk Trajectories of Readmission and Death in the First Year After Hospitalization for Chronic Obstructive Pulmonary Disease Am J Respir Crit Care Med. 2018 Apr 15;197(8):1009-1017.

7. García-Sanz MT, Cánive-Gómez JC, Senín-Rial L, et al. One-year and long-term mortality in patients hospitalized for chronic obstructive pulmonary disease. J Thorac Dis. 2017; 9 (3): 636‐645. doi:10.21037/jtd.2017.03.34

8. Watz, H., Tetzlaff, K., Magnussen, H. et al. Spirometric changes during exacerbations of COPD: a post hoc analysis of the WISDOM trial. Respir Res 2018; 19, 251.

9. Pavord ID, Jones PW, Burgel PR, Rabe KF. Exacerbations of COPD. Int J Chron Obstruct Pulmon Dis. 2016; 11 (Spec Iss): 21–30.

10. Leidy NK, Murray LT, Jones P, Sethi S. Performance of the EXAcerbations of Chronic Pulmonary Disease Tool Patient-Reported Outcome Measure in Three Clinical Trials of Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc. 2014; 11: 316-325

11. Langsetmo L, Platt RW, Ernst P, Bourbeau J. Underreporting Exacerbation of Chronic Obstructive Pulmonary Disease in a Longitudinal Cohort. Am J Respir Crit Care Med. 2008; 177: 396-401

12. Xu W, Collet J-P, Shapiro S, et al. Negative impacts of unreported COPD exacerbations on health-related quality of life at 1 year. Eur Respir J. 2010; 35: 1022-1030

13. Wilkinson TMA, Donaldson GC, Hurst JR, et al. Early Therapy Improves Outcomes of Exacerbations of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2004; 169: 1298-1303.

14. Halpin DMG, Decramer M, Celli BR, et al. Effect of a single exacerbation on decline in lung function in COPD. Respiratory Medicine 2017; 128: 85-91.

15. Dransfield MT Kunisaki KM, Strand MJ, et al. Acute Exacerbations and Lung Function Loss in Smokers With and Without Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2017; 195: 324-330

16. Miravitlles M, Anzueto A, Legnani D, et al. Patient’s perception of exacerbations of COPD: the PERCEIVE study. Respir Med. 2007; 101 (3): 453–460

17. Donaldson GC, Hurst JR, Smith CJ, et al. Increased risk of myocardial infarction and stroke following exacerbation of COPD. Chest. 2010; 137 (5): 1091‐1097.


Veeva ID: Z4-24458
Date of preparation: June 2020
Date of expiration: June 2022