Practice ABC of chronic obstructive pulmonary disease

Acute exacerbations

BMJ 2006; 333 doi: (Published 06 July 2006) Cite this as: BMJ 2006;333:87
  1. Graeme P Currie, specialist registrar,
  2. Jadwiga A Wedzicha, professor
  1. Respiratory Unit, Aberdeen Royal Infirmary, Aberdeen.
  2. Academic Unit of Respiratory Medicine, Royal Free and University College Medical School, University College London, London.

    An exacerbation of chronic obstructive pulmonary disease (COPD) is a sustained worsening of respiratory symptoms that is acute in onset and usually requires a patient to seek medical help or alter treatment. The deterioration must be more severe than the usual daily variation experienced. Exacerbations are characterised by increased breathlessness, cough, sputum volume or purulence, wheeze, and chest tightness. Other common features are malaise, reduced exercise tolerance, peripheral oedema, accessory muscle use, confusion, and cyanosis. Other (often coexisting) cardiorespiratory disorders can also cause these symptoms, which may lead to diagnostic uncertainty.

    Nebulised bronchodilators are often given during an exacerbation of COPD

    Exacerbations of COPD account for up to 10% of all medical admissions to UK hospitals, equating to more than 100 000 admissions a year, with a mean length of stay of over a week. Exacerbations therefore have considerable costs for secondary care and are partly responsible for high occupancy rates of hospital beds. Patients with frequent exacerbations have an accelerated decline in lung function, impaired quality of life, and restricted daily living activities, and, as a consequence, are likely to become housebound. As the disease becomes more severe, the frequency of exacerbations also increases.

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    Differential diagnosis of an exacerbation of COPD


    Exacerbations of COPD are mainly caused by viruses, bacteria, or environmental pollutants, though the precise cause remains unknown in many cases. Viruses play a important aetiological role, with rhinoviruses being implicated most often. How many exacerbations are caused by bacteria is uncertain, as pathogenic bacteria can often be grown from the sputum of clinically stable patients. However, one suggestion is that the isolation of a new strain may be associated with development of an exacerbation.

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    Investigations for patients admitted to hospital with exacerbation of COPD


    Oxygen therapy

    Patients admitted to hospital with an exacerbation should be given oxygen to maintain …

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