Treatment of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Treatment of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Stockley Robert A, Ward Helen
Citation: European Respiratory Disease 2009;5(1):32-36
Published: August 2009
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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 nonpharmacological 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. E: Helen.Ward3@uhb.nhs.uk

Chronic obstructive pulmonary disease (COPD) affects an estimated 210 million patients worldwide1 and accounted for 2.4% of acute medical 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 correlates with the severity of the disease as defined by forced expiratory volume in one second (FEV1),3 BODE index (body mass index [BMI], airflow obstruction [FEV1], dyspnoea and exercise capacity),4 Saint George’s Respiratory Questionnaire (SGRQ),5 increasing age and co-morbidity. In-hospital mortality ranges from 10 to 60%,6 with an allcause mortality of up to 49% within three years after hospitalisation.7 Acute exacerbations of COPD have a significant negative impact on the patient’s life. Exacerbations have been shown to cause increased mortality, more rapid decline in lung function and reduced quality of life;6,8 they also incur a large socioeconomic burden.9 A subgroup of COPD patients has been identified who suffer 2.5 to three exacerbations per year.2 This group has been shown to have increased inflammatory markers when stable,10 increased risk of being housebound, 11 chronic sputum production,12 more viral infections and increased airway bacterial load,13 and are prone to readmission.9,14 This suggests that this sub-group should be targeted for more aggressive preventative therapy.

Definition of Acute Exacerbation
Many different definitions of an exacerbation of COPD have been proposed15 and are either treatment- or symptom-based. The difficulty in definition has arisen due to the large variety of symptoms suffered during an exacerbation, variable non-respiratory causes and fluctuations in day-to-day symptoms even in the stable state. Anthonsien et al.16 defined three types of exacerbation based on symptoms of the episode:

  • type 1: new or increased sputum purulence, increased sputum volume and increased breathlessness;
  • type 2: any two of the above changes; and
  • type 3: any one of the type 1 symptoms and at least two additional features, including sore throat, nasal discharge within previous five days, unexplained fever, increased wheeze, cough or a 20% increase in heart rate or respiratory rate compared with baseline.

    Patients with type 1 exacerbations showed a benefit from antibiotic treatment,16 and this has been incorporated into the British Thoracic Society (BTS) guidelines.17 However, it is the change in sputum purulence that indicates new bacterial isolation or a rise in existing colonisation numbers,18 suggesting that this feature is the key indicator for successful antibiotic therapy.

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