infective exacerbations of COPD

Last edited 12/2018

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, is acute in onset and requires additional therapy.

• 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 beathlessness
    
    
  • 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 the chest radiograph are present
    
    
  • arterial pH level < 7.35
    
    
  • arterial PaO2 < 7 kPa

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

Reference:

• (1) National Institute for Health and Clinical Excellence (NICE) 2018. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care.
• (2) Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.