Infective exacerbations of COPD

An exacerbation can be defined as a sustained worsening of the patient's symptoms from his or her usual stable state that is beyond normal day-to-day variations, and is acute in onset.

• worsening breathlessness is the key symptom of an exacerbation
  • other symptoms include - increased sputum production and change in sputum colour together with increased cough and wheeze (1,2)

A number of factors have been identified as the cause of exacerbation of COPD:

• the cause may be unidentified in around 30% of exacerbations
• infections -
  • viruses - rhinoviruses (common cold), RSV, influenza, parainfluenza,
  • bacteria - H influenza, S pneumonia, Staph aureus,
• common pollutants - nitrogen dioxide, sulphur dioxide, particulates (1)

Exacerbations can be classified as (1)

• mild - can be controlled with an increase in dosage of regular medications
• moderate - requires treatment with systemic corticosteroids or antibiotics
• severe - requires hospitalization or evaluation in the emergency department (may also be associated with acute respiratory failure) (2)
• factors which favour treatment in hospital
  • not able to cope at home
  • severe breathlessness
  • general condition is poor/ deteriorating
  • level of activity is poor/confined to bed
  • cyanosis is present
  • worsening peripheral oedema
  • impaired level of consciousness
  • patients is already receiving long term oxygen therapy
  • patient is living alone/ not coping
  • acute confusion is present
  • exacerbation has had a rapid rate of onset
  • there is significant comorbidity particularly cardiac disease and insulin-dependent diabetes)
  • SaO2 < 90%
  • changes on chest radiograph
  • arterial pH level < 7.35
  • arterial PaO2 < 7 kPa

For further details, consult the full guideline (1).

Reference:

1. National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Jul 2019 [internet publication].
2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2025 report. 2025 [internet publication].