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Acute exacerbation of chronic obstructive pulmonary disease

acute exacerbation of chronic obstructive pulmonary disease, acute exacerbation of chronic obstructive pulmonary disease (copd)

Acute exacerbation of COPD also known as acute exacerbations of chronic bronchitis AECB is a sudden worsening of COPD symptoms shortness of breath, quantity and color of phlegm that typically lasts for several days It may be triggered by an infection with bacteria or viruses or by environmental pollutants Typically, infections cause 75% or more of the exacerbations; bacteria can roughly be found in 25% of cases, viruses in another 25%, and both viruses and bacteria in another 25% Airway inflammation is increased during the exacerbation resulting in increased hyperinflation, reduced expiratory air flow and decreased gas exchange12

As COPD progresses, exacerbations tend to become more frequent, the average being about three episodes per year3


  • 1 Signs and symptoms
  • 2 Causes
  • 3 Diagnosis
  • 4 Prevention
  • 5 Treatment
    • 51 Oxygen
    • 52 Medications
    • 53 Mechanical ventilation
  • 6 Epidemiology
  • 7 References

Signs and symptomsedit

An acute exacerbation of COPD is associated with increased frequency and severity of coughing4 It is often accompanied by worsened chest congestion and discomfort Shortness of breath and wheezing are present in many cases4 Exacerbations may be accompanied by increased amount of cough and sputum productions, and a change in appearance of sputumcitation needed An abrupt worsening in COPD symptoms may cause rupture of the airways in the lungs, which in turn may cause a spontaneous pneumothorax3

In infection, there is often weakness, fever and chills If due to a bacterial infection, the sputum may be slightly streaked with blood and coloured yellow or green4


As the lungs tend to be vulnerable organs due to their exposure to harmful particles in the air, several things can cause an acute exacerbation of COPD:

  • Respiratory infection, being responsible for approximately half of COPD exacerbations Approximately half of these are due to viral infections and another half appears to be caused by bacterial infections5 Common bacterial pathogens of acute exacerbations include Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis6 Less common bacterial pathogens include Chlamydia pneumoniae and MRSA6 Pathogens seen more frequently in patients with impaired lung function FEV<35% of predicted include Haemophilus parainfluenzae after repeated use of antibiotics, Mycoplasma pneumoniae and gram-negative, opportunistic pathogens like Pseudomonas aeruginosa and Klebsiella pneumoniae6
  • Allergens, eg, pollens, wood or cigarette smoke, pollution4
  • Toxins, including a variety of different chemicals4
  • Air pollutioncitation needed
  • Failing to follow a drug therapy program, eg improper use of an inhalercitation needed

In one-third of all COPD exacerbation cases, the cause cannot be identifiedcitation needed


See also: COPD § Diagnosis

The diagnostic criteria for acute exacerbation of COPD generally include a production of sputum that is purulent6 and may be thicker4 than usual, but without evidence of pneumonia which involves mainly the alveoli rather than the bronchi4 Also, diagnostic criteria may include an increase in frequency and severity of coughing,4 as well as increased shortness of breath6

A chest X-ray is usually performed on people with fever and, especially, hemoptysis blood in the sputum, to rule out pneumonia and get information on the severity of the exacerbation Hemoptysis may also indicate other, potentially fatal, medical conditions4

A history of exposure to potential causes and evaluation of symptoms may help in revealing the cause the exacerbation, which helps in choosing the best treatment A sputum culture can specify which strain is causing a bacterial AECB4 An early morning sample is preferred6

E-nose showed the ability to smell the cause of the exacerbation 7

The definition of a COPD exacerbation is commonly described as "lost in translation,"8 meaning that there is no universally accepted standard with regard to defining an acute exacerbation of COPD Many organizations consider it a priority to create such a standard, as it would be a major step forward in the diagnosis and quality of treatment of COPD


Acute exacerbations can be partially prevented Some infections can be prevented by vaccination against pathogens such as influenza and Streptococcus pneumoniae Regular medication use can prevent some COPD exacerbations; long acting beta-adrenoceptor agonists LABAs, long-acting anticholinergics, inhaled corticosteroids and low-dose theophylline have all been shown to reduce the frequency of COPD exacerbations9101112 Other methods of prevention include:

  • Smoking cessation and avoiding dust, passive smoking, and other inhaled irritants4
  • Yearly influenza and 5-year pneumococcal vaccinations4
  • Regular exercise, appropriate rest, and healthy nutrition4
  • Avoiding people currently infected with eg cold and influenza4
  • Maintaining good fluid intake and humidifying the home, in order to help reduce the formation of thick sputum and chest congestion4



Oxygen therapy should be initiated if there is significantly low blood oxygen High flow oxygen may be harmful in those with an acute exacerbation of COPD In the prehospital environment those given high flow O2 rather than titrating their O2 saturations to 88% to 92% had worse outcomes13


  • Inhaled bronchodilators open up the airways in the lungs14 These include salbutamol and terbutaline both β2-adrenergic agonists, and ipratropium an anticholinergic4 Medication can be administered via inhaler or nebuliser There is no evidence to prefer a nebuliser over an inhaler 15
  • Antibiotics are used if a bacterial infection is the suspected cause4 However, antibiotics will not treat exacerbations caused by viruses Viral infections will usually be cured with time with the aid of proper rest and care Still, other medications may be needed to control symptoms4 Lipid-soluble antibiotics such as macrolides, tetracyclines, and quinolones penetrate the lung tissue well6 Macrolides are more active against Streptococcus pneumoniae than the tetracyclines and the older quinolones6 Within the macrolides, newer ones are more active against Haemophilus influenzae than the older erythromycin Regimens should generally be given for five days6 Choice of antibiotics is also dependent on the severity of the symptoms:
    • "Simple" COPD is generally where a person 65 years or less, has fewer than four exacerbations per year, has minimal or moderate impairment in respiratory function and no comorbid disease6 In patients with "simple" COPD, therapy should be targeted towards Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae, and possibly pathogens of atypical pneumonia6 The first-line treatment is a beta-lactam antibiotic such as amoxicillin The choice will depend on resistance patterns6 In patients with penicillin allergy, doxycycline or trimethoprim are preferred6
    • More complicated bronchitis may be when the patient is more than 65 years old, has four or more exacerbations per year, has an FEV1/FVC ratio of less than 50% on spirometry, has failed to respond to previous antibiotic treatment, and/or has comorbidity6 In these cases, treatment should be aimed at Gram-negative bacteria and the possibility of high antibiotic resistance should be considered6 Sputum culture results are of great value in determining antibiotic resistance6 First-line treatment is cefuroxime or co-amoxiclav6 Third-line treatment, as well as treatment in penicillin-allergic patients, is a fluoroquinolone such as ciprofloxacin6 An agent active against Streptococcus pneumoniae may have to be added6
  • Corticosteroids such as prednisone reduce inflammation in the airways14 According to systematic review, a shorter, five-day course of systemic corticosteroids is likely comparable to longer 10-14 day therapy for treatment of COPD exacerbation Odds ratio OR 072, 95% confidence interval CI 036 to 146 16
  • Theophylline is generally not recommended

There should also be a "care plan" in case of future exacerbations Patients may watch for symptoms, such as shortness of breath, change in character or amount of mucus, and start self-treatment as discussed with a health care provider This allows for treatment right away until a doctor can be seen4

The symptoms of acute exacerbations are treated using short-acting bronchodilators A course of corticosteroids, usually in tablet or intravenous rather than inhaled form, can speed up recovery1 The IV and oral forms of steroids have been found to be equivalent17 Antibiotics are often used but will only help if the exacerbation is due to an infection18 Antibiotics are indicated when a patient notes increased sputum production,5 purulent sputum,5 increased dyspnea,5 has an elevated white count, or is febrile Examples of first-line antibiotics are amoxicillin,5 doxycycline5 and co-trimoxazole5

Mechanical ventilationedit

Severe exacerbations can require hospital care where treatments such as oxygen and mechanical ventilation may be required19 Mechanical ventilation can be invasive endotracheal intubation or non-invasive forms of ventilation such as continuous positive airway pressure


The incidence varies depending on which definition is used, but definitions by Anthonisen et al20 the typical COPD patient averages two to three AECB episodes per year21 With a COPD prevalence of more than 12 million possibly 24 million including undiagnosed ones in the United States,22 there are at least 30 million incidences of AECB annually in the US


  1. ^ a b Rabe KF, Hurd S, Anzueto A, et al 2007 "Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive Summary" Am J Respir Crit Care Med 176 6: 532–55 PMID 17507545 doi:101164/rccm200703-456SO 
  2. ^ van Geffen WH, Slebos DJ, Kerstjens HA "Hyperinflation in COPD exacerbations" The Lancet Respiratory Medicine 3 12: 43–44 doi:101016/S2213-26001500459-2 
  3. ^ a b "Chronic Obstructive Pulmonary Disease COPD" Merck Sharp & Dohme Corp Retrieved 19 May 2014 
  4. ^ a b c d e f g h i j k l m n o p q r s > Acute Exacerbations of Chronic Bronchitis Retrieved March 13, 2010
  5. ^ a b c d e f g Uppsala Academic Hospital > Guidelines for treatment of acute lung diseases August 2004 Authors: Christer Hanson, Carl-Axel Karlsson, Mary Kämpe, Kristina Lamberg, Eva Lindberg, Lavinia Machado Boman, Gunnemar Stålenheim
  6. ^ a b c d e f g h i j k l m n o p q r s The British Society for Antimicrobial Chemotherapy > Acute exacerbations of chronic bronchitis AECB Archived 2006-04-06 at the Wayback Machine Retrieved March 13, 2010
  7. ^ Geffen, Wouter H van; Bruins, Marcel; Kerstjens, Huib A M 2016-01-01 "Diagnosing viral and bacterial respiratory infections in acute COPD exacerbations by an electronic nose: a pilot study" Journal of Breath Research 10 3: 036001 ISSN 1752-7163 doi:101088/1752-7155/10/3/036001 
  8. ^ Makris D, Bouros D January 2009 "COPD Exacerbtion: Lost in Translation" BMC Pulm Med 9 6: 6 PMC 2640343  PMID 19178701 doi:101186/1471-2466-9-6 
  9. ^ Calverley PM, Anderson JA, Celli B, et al 2007 "Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease" N Engl J Med 356 8: 775–89 PMID 17314337 doi:101056/NEJMoa063070 
  10. ^ Tashkin DP, Celli B, Senn S, et al October 2008 "A 4-year trial of tiotropium in chronic obstructive pulmonary disease" The New England Journal of Medicine 359 15: 1543–54 PMID 18836213 doi:101056/NEJMoa0805800 
  11. ^ Zhou Y, Wang X, Zeng X, et al 2006 "Positive benefits of theophylline in a randomized, double-blind, parallel-group, placebo-controlled study of low-dose, slow-release theophylline in the treatment of COPD for 1 year" Respirology 11 5: 603–10 PMID 16916334 doi:101111/j1440-1843200600897x 
  12. ^ Burge PS, Calverley PM, Jones PW, Spencer S, Anderson JA, Maslen TK 2000 "Randomised, double blind, placebo controlled study of fluticasone propionate in patients with moderate to severe chronic obstructive pulmonary disease: the ISOLDE trial" BMJ 320 7245: 1297–303 PMC 27372  PMID 10807619 doi:101136/bmj32072451297 
  13. ^ Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R 2010 "Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial" BMJ 341: c5462 PMC 2957540  PMID 20959284 doi:101136/bmjc5462 
  14. ^ a b Bach PB, Brown C, Gelfand SE, McCrory DC 2001 "Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence" Ann Intern Med 134 7: 600–20 PMID 11281745 doi:107326/0003-4819-134-7-200104030-00016 
  15. ^ "Bronchodilators delivered by nebuliser versus pMDI with spacer or DPI for exacerbations of COPD" ISSN 1465-1858 doi:101002/14651858cd011826pub2/abstract 
  16. ^ Walters, JA; Tan, DJ; White, CJ; Wood-Baker, R 10 December 2014 "Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease" The Cochrane database of systematic reviews 12: CD006897 PMID 25491891 doi:101002/14651858CD006897pub3 
  17. ^ Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB June 2010 "Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease" JAMA 303 23: 2359–67 PMID 20551406 doi:101001/jama2010796 
  18. ^ Gibson, et al Evidence-based Respiratory Medicine Blackwell Publishing, 2005 ISBN 0-7279-1605-X pp 390-392
  19. ^ Quon BS, Gan WQ, Sin DD March 2008 "Contemporary management of acute exacerbations of COPD: a systematic review and metaanalysis" Chest 133 3: 756–66 PMID 18321904 doi:101378/chest07-1207 
  20. ^ Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA February 1987 "Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease" Ann Intern Med 106 2: 196–204 PMID 3492164 doi:107326/0003-4819-106-2-196 
  21. ^ Page 249 in: Balter MS, La Forge J, Low DE, Mandell L, Grossman RF 2003 "Canadian guidelines for the management of acute exacerbations of chronic bronchitis" Can Respir J 10 Suppl B: 3B–32B PMID 12944998  "Archived copy" PDF Archived from the original PDF on 2013-10-19 Retrieved 2013-10-18 
  22. ^ MORBIDITY & MORTALITY: 2009 CHART BOOK ON CARDIOVASCULAR, LUNG, AND BLOOD DISEASES Archived October 19, 2013, at the Wayback Machine National Heart, Lung, and Blood Institute

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