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Chronic Obstructive Pulmonary Disease
Treatment of Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Helen Ward
1
and Robert A Stockley
2
1. Clinical Research Fellow; 2. Professor of Medicine, Department of Respiratory Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham
Abstract
Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality worldwide. Exacerbations in particular are an
important contributor to the substantial mortality and have a large financial impact as well as a negative impact on quality of life and decline
in lung function. This general review reflects on important aspects in the management of acute COPD exacerbations, including the definition
of exacerbation (and important differential diagnoses), pathogenesis, causes and management, including pharmacological and non-
pharmacological interventions. We have included general treatment algorithms and guidance towards more specific therapies. Prevention is
a key future strategy and several recent trials have confirmed efficacy in reducing but not preventing exacerbations. A better understanding
of the nature of the episodes and more targeted future therapies or self-management plans are required to prevent or minimise all episodes.
Keywords
Chronic obstructive pulmonary disease (COPD), exacerbation, management
Disclosure: The authors have no conflicts of interest to declare.
Received: 13 January 2009 Accepted: 16 June 2009
Correspondence: Helen Ward, Department of Respiratory Medicine, First Floor, Nuffield House, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
Helen.Ward3@uhb.nhs.uk
Chronic obstructive pulmonary disease (COPD) affects an estimated 210 Anthonsien et al.
16
defined three types of exacerbation based on
million patients worldwide
1
and accounted for 2.4% of acute medical symptoms of the episode:
admissions in England in 2003–2004.
2
COPD is also a significant cause of
mortality, causing 3 million deaths globally in 2005.
1
The mortality rate • type 1: new or increased sputum purulence, increased sputum
correlates with the severity of the disease as defined by forced volume and increased breathlessness;
expiratory volume in one second (FEV
1
),
3
BODE index (body mass index • type 2: any two of the above changes; and
[BMI], airflow obstruction [FEV
1
], dyspnoea and exercise capacity),
4
Saint • type 3: any one of the type 1 symptoms and at least two additional
George’s Respiratory Questionnaire (SGRQ),
5
increasing age and features, including sore throat, nasal discharge within previous five
co-morbidity. In-hospital mortality ranges from 10 to 60%,
6
with an all- days, unexplained fever, increased wheeze, cough or a 20% increase
cause mortality of up to 49% within three years after hospitalisation.
7
in heart rate or respiratory rate compared with baseline.
Acute exacerbations of COPD have a significant negative impact on the Patients with type 1 exacerbations showed a benefit from antibiotic
patient’s life. Exacerbations have been shown to cause increased treatment,
16
and this has been incorporated into the British Thoracic
mortality, more rapid decline in lung function and reduced quality of Society (BTS) guidelines.
17
However, it is the change in sputum purulence
life;
6,8
they also incur a large socioeconomic burden.
9
A subgroup that indicates new bacterial isolation or a rise in existing colonisation
of COPD patients has been identified who suffer 2.5 to three numbers,
18
suggesting that this feature is the key indicator for successful
exacerbations per year.
2
This group has been shown to have increased antibiotic therapy.
inflammatory markers when stable,
10
increased risk of being house-
bound,
11
chronic sputum production,
12
more viral infections and The definition of an exacerbation that has been adopted by the Global
increased airway bacterial load,
13
and are prone to readmission.
9,14
This Initiative for Chronic Obstructive Lung Disease (GOLD)
19
as defined in a
suggests that this sub-group should be targeted for more aggressive consensus statement
20
is: “a sustained worsening of the patient’s
preventative therapy. condition, from the stable state and beyond the normal day-to-day
variations, that is acute in onset and necessitates a change in regular
Definition of Acute Exacerbation medications in a patient with underlying COPD”. This symptom-based
Many different definitions of an exacerbation of COPD have been definition recognises that there is variability in usual symptoms but that
proposed
15
and are either treatment- or symptom-based. The difficulty in an acute deterioration has to be persistent to be recognised as an acute
definition has arisen due to the large variety of symptoms suffered exacerbation. This definition requires an intervention, and studies using
during an exacerbation, variable non-respiratory causes and diary card monitoring show that symptomatic changes indicative of an
fluctuations in day-to-day symptoms even in the stable state. exacerbation can occur without the patient requiring a change of
32 © TOUCH BRIEFINGS 2009
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