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Treating and Preventing COPD Exacerbations Exacerbations of chronic obstructive pulmonary disease (COPD) are common and have serious implications. They are distressing The following are signs of a severe exacerbation:1
and disruptive for patients, and account for a significant proportion of the total costs of caring for patients with COPD.1 Acute exacerbations of COPD are the second most common cause for emergency medical admissions and carry a 15% mortality within • Use of accessory muscles (sternomastoid and abdominal) at rest• Acute confusion What is an exacerbation?
According to NICE and the British Thoracic Society (BTS) guidelines, a COPD exacerbation is a worsening of the • Marked reduction in activities of daily living previous stable situation, and may include: These may not all be present, but the occurrence of any of these should alert the clinician. Other features suggesting • Increase in sputum volume or purulence the need for emergency admission include chest pains and • Complaints of general malaise and/or fever Managing exacerbations
Exacerbations should be managed aggressively with the aims of: All of these changes are generally acute in onset andnecessitate a change in medication.
• Alleviating symptoms• Preventing disease progression Exacerbations usually cause a decline in functional ability and the recovery time is slow, often taking six months. Those who suffer • Improving performance of activities of daily living.
from frequent exacerbations do not recover completely from one exacerbation before the next arrives, thus they suffer from faster Patients at risk of an exacerbation should be encouraged to be decline in health status and lung function.4 vigilant with regards to exacerbation symptoms and to respond • Increase frequency of short-acting bronchodilator use (e.g. salbutamol 800mcg-1200mcg 3hrly via MDI and a spacer). A nebuliser should be used if the patient is unable to use a MDI plus spacer (always specify driving gas and prescribe with compressed air if the person is hypercapnic/acidotic). The delivery system should reflect the patient’s ability to use it, • History of long term oxygen therapy.
the dosage and the resources available for supervision • Starting oral antibiotics (e.g amoxycillin 500mg three times What causes an exacerbation?
daily for 7 days or clarithromycin 500mg twice daily for 7 days if penicillin allergic) if sputum is purulent or there are clinical The most common causes of exacerbation are bacterial or signs of pneumonia. Either an aminopenicillin, a macrolide or viral infection. Enviromental factors such as pollution can also contribute. However, the cause of about 30% of exacerbations • With recurrent infective exacerbations sputum culture is cannot be identified.6 It is important to consider alternative indicated and the possibility of bronchiectasis or even cystic diagnoses such as pneumothorax, pulmonary embolus or worsening of pre-existing heart failure.
• Starting oral prednisolone 30mg daily for 7–14 days (there is no advantage in prolonging therapy). Prednisolone is a Assessment of the severity of an exacerbation
corticosteroid needed for all exacerbations that do not promptly respond to bronchodilator use Some exacerbations are mild and self-limiting and these can be managed by patients at home without consulting healthcare Home supplies of antibiotic and prednisolone are appropriate for professionals. Severe exacerbations carry a risk of death and most patients with recurrent exacerbations but should be used with a written action plan and their consumption monitored. Patients should be encouraged to inform their usual medical care contacts The severity of an exacerbation should be assessed and a about any changes to their medication.
plan of management established. The sooner action is taken the better as early drug treatment reduces the impact of the exacerbation.

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Pulse oximetry should be measured and hypoxia treated with What you need to know
oxygen in an emergency, but with due respect for the possibility of hypercapnoea. Oxygen should be provided to restore the saturations COPD exacerbation is a worsening of the previous stable
to a target range of 88-92% using oxygen at 24-28% (or 2-4l/ situation and may include:
min), pending transfer to hospital. It is important to note that home • Increased breathlessness
oxygen should not be provided if the patient becomes hypoxic with • Cough
an exacerbation, instead they should be admitted to hospital. If the • Increase in sputum volume or purulence
patient was hypoxic before the exacerbation they should be referred • Wheeze
for long term oxygen therapy (LTOT) assessment. Recovery from an • Chest tightness
exacerbation should also be monitored carefully, with patients being • Complaints of general malaise and/or fever
followed-up 2 to 6 weeks after an exacerbation. The following are signs of a severe exacerbation: 1
Monitoring recovery from an exacerbation1
• Marked dyspnoea
• Tachypnoea
• Establish on optimal drug treatment, pulmonary • Purse lip breathing
rehabilitation, (this is not suitable for patients who are • Use of accessory muscles at rest
unable to walk, have unstable angina or who have had a • Acute confusion
recent myocardial infarction),1 nutrition and treatment for • New onset cyanosis
• New onset peripheral oedema
• Arrange multidisciplinary assessment if necessary • Marked reduction in activities of daily living
• Give clear instructions about correct use of medications • Hypoxia
(including oxygen) and stopping corticosteroid therapy. Ensure patients are aware of the optimum duration of treatment and The occurrence of any of these should necessitate
the adverse effects of prolonged oral corticosteroid alerting a clinician as soon as possible. Features
therapy. Review the need for osteoporosis prophylaxis suggesting the need for emergency admission also
include chest pains and high fever.
Preventing future exacerbations
Patients at risk of an exacerbation should be encouraged
Health promotion strategies which may help to lower the risk of to be vigilant and to respond quickly by:1
future exacerbations include patient and family education on early • Increasing the frequency of bronchodilator use
recognition of symptoms of deterioration, smoking cessation • Starting oral antibiotics if sputum is purulent or there are
strategies and participation in pulmonary rehabilitation. Such clinical signs of pneumonia
proactive management can assist in reducing the long-term • Starting oral prednisolone 30mg daily for 7–14 days
morbidity associated with this chronic disease. All patients at risk of exacerbations should be reviewed at regular intervals, e.g. every 6 Think about.
months as well as after each exacerbation. • Would you know how to recognise an exacerbation?
Treatment options for preventing exacerbations
• Do you understand which signs and symptoms are
typical of a severe exacerbation?
Treatment
NICE guidance1
• What advice would you give to patients at risk of
In patients with a history of exacerbations, an exacerbation?
bronchodilators: despite taking short-acting bronchodilators, LABA or LAMA Glossary
either a long-acting beta agonist (LABA) Acidotic: An abnormal condition resulting from excess acid production;
(e.g. salmeterol or formoterol) or long-acting cyanosis: a bluish or purplish discoloration of skin due to deficient
muscarinic antagonist (LAMA) (tiotropium) oxygenation of the blood; dyspnoea: difficult or laboured breathing;
Patients with a history of exacerbations FEV : forced expiratory volume in 1 second, the volume of air
bronchodilators: whose FEV <50% predicted: offer either a breathed out in that time from full lungs (a measure of lung function); Hypercapnic: the physical condition of having the presence of an
LABA with an ICS in a combination inhaler, abnormally high level of carbon dioxide in the circulating blood; Hypoxia:
is a pathological condition in which the body as a whole (generalised hypoxia) or a region of the body (tissue hypoxia) is deprived of adequate oxygen supply; Peripheral oedema: abnormal accumulation of fluid in
(e.g. Symbicort or Seretide) in people with the body tissues or cavities causing swelling or distention of the affected parts; Peripheral oedema refers to swelling in the lower limbs / ankles; Pneumothorax: the abnormal presence of air between the lung and
the wall of the chest (pleural cavity), resulting in collapse of the lung; Purulence: The condition of containing or discharging pus; Tachypnoea:
against pneumococcal disease and receive abnormally rapid breathing or respiration References
1. National Clinical Guideline Centre. (2010) Chronic obstructive pulmonary disease:
Self-management For patients at risk of exacerbations provide management of chronic obstructive pulmonary disease in adults in primary and a course of antibiotic and corticosteroid secondary care. London: National Clinical Guideline Centre. Available from: http:// tablets to keep at home. Monitor the use of guidance.nice.org.uk/CG101/Guidance/pdf/English 2. Royal College of Physicians.
The National COPD Audit 2008. Royal College of Physicians, 2008. 3. The COPD
these drugs and advise patients to contact a Guidelines Group of the Standards of Care Committee of the British Thoracic Society. healthcare professional if their symptoms do BTS guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997; 52 (Suppl 5): S1–28. 4. Donaldson GC, Seemungal TA, Bhowmik A, Wedzicha
JA. Relationship between exacerbation frequency and lung function decline in chronic
obstructive pulmonary disease.Thorax 2002;57:847-852 5. N. Roche, M. Zureik, D.
The COPDexchange action plan helps patients recognise the
Soussan, F. Neukirch, D. Perrotin. Predictors of outcomes in COPD exacerbation symptoms of an exacerbation and understand what to do when cases presenting to the emergency department Eur Respir J 2008 32:953-961 6.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the
an exacerbation happens. Download the action plan for your Diagnosis, Management and Prevention of COPD (updated 2010). Gig Harbor, WA, patients from the COPDexchange ‘Tools’ section.
USA: December 2010. Available from: http://www.goldcopd.org The COPDexchange medical education initiative was developed and funded by Boehringer Ingelheim Ltd and Pfizer Ltd. COPDexchange is peer reviewed and the editorial panel have retained final editorial control of the content. The opinions expressed in COPDexchange are not necessarily those of Boehringer Ingelheim Ltd and Pfizer Ltd. 2011 Boehringer Ingelheim. All rights reserved.
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SPI/SPV2682a Date of preparation: April 2011

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