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Chronic obstructive pulmonary disease (COPD) exacerbations are important events in COPD and are major determinants of health status in COPD.
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The natural course of COPD is interrupted by episodes of respiratory symptom worsening, termed exacerbations.
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Optimal management of acute exacerbations not only increases the rate of exacerbation recovery but also affects exacerbation rates and prevents hospital admissions.
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There is a need for the development of novel antiinflammatory agents that are
Acute COPD Exacerbations
Section snippets
Key points
Impact of COPD exacerbations
The natural course of COPD is interrupted by episodes of respiratory symptom worsening, termed exacerbations.1 COPD exacerbations are important events in COPD and are major determinants of health status in COPD. COPD exacerbations are also independent predictors of mortality in COPD and also drive disease progression, with approximately 25% of the lung function decline attributed to exacerbations.2
COPD is the second largest cause of emergency admissions in the United Kingdom, with 1 in 8
Definition of exacerbations
The common symptoms of a COPD exacerbation are increase in dyspnea, sputum purulence, and cough, but other symptoms may include increased wheezing, chest discomfort, and symptoms of an upper airway cold. Physiologic changes at COPD exacerbations (eg, falls in peak flow or FEV1) are generally small and not useful in predicting or monitoring exacerbations.1
An exacerbation of COPD is defined in the GOLD strategy in terms of health care utilization as “an acute event characterised by a worsening of
Causes and pathogenesis of exacerbation
A majority of COPD exacerbations are triggered by respiratory viral infections, especially rhinovirus, the cause of the common cold. Using molecular techniques, respiratory viruses can be identified in up to 60% of exacerbations.11 Exacerbations associated with viruses tend to have greater airway and systemic inflammatory effects than those without any evidence of viral infection and are more common in the winter months, with more chance of hospital admission. Airway pollutants may also be
The frequent exacerbator phenotype
Exacerbations become more frequent and severe as COPD severity increases. One distinct group of patients seems susceptible to exacerbations, irrespective of disease severity. This COPD phenotype of frequent exacerbations is stable over time and the major determinant of developing frequent exacerbations is a history of prior exacerbations.13 This phenomenon is seen across all GOLD stages, including patients with stage 2 disease, of whom 22% had frequent exacerbations in the first year of the
Vaccines
In retrospective cohort studies of community-dwelling elderly patients, influenza vaccination is associated with a 27% reduction in the risk of hospitalization for pneumonia or influenza and a 48% reduction in the risk of death.16 Thus, influenza vaccines are recommended in a majority of patients with COPD. There is less evidence for the role of pneumococcal polysaccharide vaccine in preventing exacerbations and hospital admissions in COPD, but large studies are currently under way with
Management of the acute exacerbation
After the earlier studies of Anthonisen and colleagues,27 the standard management of an acute exacerbation consists of oral antibiotics, such as amoxicillin or doxycycline, if there is evidence of increased sputum purulence or increased sputum volume. Oral corticosteroids in short courses are also added depending on individual exacerbation severity, and there is recent evidence suggesting that shorter courses (5 days) may be as beneficial as longer ones, such as more conventional 14-day courses.
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Conflicts of Interest: J.A. Wedzicha has received honoraria for lectures and/or advisory boards from GSK, Novartis, Boehringer, Pfizer, Bayer, Takeda, and Vifor Pharma. She has received research grants from Novartis, Johnson and Johnson, Takeda, and Chiesi.