Acute exacerbation of COPD
An acute exacerbation of COPD is a change in baseline dyspnea, cough, or sputum that requires a change in therapy, most often triggered by viral or bacterial respiratory infection. Severity is graded by the treatment required, and management is a stepwise sequence of bronchodilators, glucocorticoids, targeted oxygen, and, when hypercapnic acidosis is present, noninvasive ventilation.
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What this article covers
- Overview
Definition: an acute exacerbation of chronic obstructive pulmonary disease (COPD) is a worsening of a patient's typical symptoms, beyond normal day-to-day variation, that leads to a change in medical…
- Epidemiology
High burden in known COPD: patients with established COPD, particularly with more severe airflow obstruction, experience recurrent exacerbations over the disease course.
- Risk factors
Prior exacerbation history: two or more exacerbations in the past year, the strongest predictor of a future exacerbation.
- Pathophysiology
Infectious trigger is most common: most exacerbations are triggered by a viral or bacterial respiratory infection; common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae…
- Clinical features
Dyspnea worse than the patient's baseline: the most consistent feature; ask specifically how current breathlessness compares with usual day-to-day status.
- Differential diagnosis
Community-acquired pneumonia: community-acquired pneumonia causes fever and focal signs; discriminated by a new infiltrate on chest radiograph, which a plain exacerbation lacks.
- Diagnosis
The diagnosis is clinical: an acute exacerbation of COPD is diagnosed when a patient with established COPD develops a change from baseline in dyspnea, cough, or sputum (volume or character) that…
- Management
First, assess severity and setting of care: hospitalize any patient with respiratory distress or at risk for it; treat mild exacerbations manageable with short-acting bronchodilators alone as an outpatient.
- Complications
Acute hypercapnic respiratory failure, from progressive dynamic hyperinflation, auto-PEEP, and respiratory muscle fatigue; see acute hypercapnic respiratory failure.
- Prognosis
Hospitalization for an exacerbation prolongs time to readmission and marks a higher-risk patient, a key marker to document at discharge and act on with prevention strategies.
- Prevention
Smoking cessation: offer counseling plus pharmacotherapy (varenicline or bupropion as dosed above, or nicotine replacement) to every patient who still smokes, since cessation slows FEV1 decline and prevents exacerbations.
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Related articles
- Chronic obstructive pulmonary disease (COPD)
Chronic obstructive pulmonary disease is a persistent, usually progressive airflow obstruction driven mainly by cigarette smoke, confirmed by a postbronchodilator FEV1/forced vital capacity (FVC) ratio below 0.70 and staged by GOLD spirometric grade plus symptom/exacerbation group. Maintenance management is a stepwise ladder of smoking cessation, long-acting bronchodilators, add-on inhaled glucocorticoid, roflumilast, or azithromycin for frequent exacerbators, long-term oxygen for resting hypoxemia, and vaccination, with acute exacerbations managed as a separate protocol.
- Acute hypercapnic respiratory failure
Acute hypercapnic (type II, ventilatory) respiratory failure is alveolar hypoventilation with arterial PCO2 above 45 mm Hg and acidemia, from pump failure or dead-space ventilation. Confirm with an arterial blood gas in every suspected patient, then treat the precipitant while titrating noninvasive or invasive ventilation to reverse the acidosis.
- Community-acquired pneumonia
Community-acquired pneumonia is a lower respiratory tract infection acquired outside the hospital that is diagnosed by a compatible clinical syndrome plus a new infiltrate on chest imaging, risk-stratified with CURB-65 or the Pneumonia Severity Index to guide site of care, and treated with empiric antibiotics chosen by site of care and comorbidity, escalating to cover MRSA or Pseudomonas aeruginosa when risk factors are present.
- Pneumothorax
Pneumothorax is air in the pleural space, occurring spontaneously (primary in structurally normal lungs, secondary in underlying lung disease) or from trauma or procedures. Management is driven by size and hemodynamic stability, ranging from observation to needle aspiration to tube thoracostomy.
- Pulmonary embolism
Pulmonary embolism is thrombus, usually from a lower-extremity deep vein thrombosis, obstructing the pulmonary arterial circulation and causing V/Q mismatch, right ventricular strain, and hypoxemia. Diagnosis follows Wells criteria (with PERC in low-risk patients) to sequence D-dimer, CT pulmonary angiography, and V/Q scanning, and management is risk-stratified anticoagulation escalating to thrombolysis or embolectomy for hemodynamic instability.
- Acute heart failure
Acute heart failure is the rapid onset or worsening of heart failure symptoms requiring urgent therapy, most often pulmonary congestion from a precipitant such as ischemia, arrhythmia, or nonadherence. Management is oxygen, intravenous diuretics, and vasodilators for the congested-but-perfused patient, with inotropes or support for the hypoperfused patient.
- Bronchiectasis
Bronchiectasis is chronic, irreversible bronchial dilation from a cycle of infection, inflammation, and airway destruction, diagnosed by high-resolution CT and managed with airway clearance, treatment of the underlying cause, and antibiotics for exacerbations.