Exacerbation of COPD is defined as “a sustained worsening of the patient's condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication”.⁷³

Patient assessment

The symptoms of an exacerbation are increased breathlessness often accompanied by wheezing, increased cough and sputum, change of the color or tenacity of sputum, and fever.

The common causes of an exacerbation are infection of the tracheobronchial tree and air pollution.^74-76 The cause of approximately one-third of severe exacerbations cannot be identified. Conditions that may mimic an acute exacerbation include pneumonia, congestive heart failure, pneuomothorax, pleural effusion, pulmonary embolism, and arrhythmias. These conditions should be ruled out by clinical examination and investigations.

The assessment of severity of acute worsening is based on the patient’s medical history before the exacerbation, symptoms, physical examination, lung function tests, arterial blood gas measurements, and other laboratory tests. The medical history should cover the period of worsening since the new symptoms have been present, the frequency and severity of breathlessness and coughing attacks, sputum volume and color, limitation of daily activities, any previous episodes/exacerbations, hospitalization, and the present treatment regimen.

Treatment of acute exacerbations

Bronchodilators are the cornerstone of managing exacerbations of COPD. Patients need to increase the dose and/or frequency of existing bronchodilator therapy. New drugs, which patient is not taking at the time of worsening, may be added. Short-acting bronchodilators should ideally be administered using inhalers (preferably with spacers). In a severe case, nebulizers may be used for drug administration. In situations where these drugs are not available, parenteral aminophylline can be used with due attention to its toxicity. Aminophylline dose should be appropriately modified in elderly patients, those in congestive cardiac failure or having liver cirrhosis, and those already taking oral methylxanthines, cimetidine, ciprofloxacin or erythromycin.

Antibiotics should be used when symptoms of breathlessness and cough are increased and sputum is purulent and increased in volume^77,78. The choice of antibiotic depends on the affordability of the patient, the severity of exacerbation and the bacterial spectrum.⁷⁹ Amoxycillin, doxycycline, cotrimoxazole, flouroquinolones or a second generation macrolide/cephalosporin are used as the first choice. For severe exacerbations higher-grade antibiotics, such as coamoxiclav or a fourth generation cephalosporin can be used.

Systemic glucocorticoids should be used in acute exacerbations. They shorten recovery time and help to restore lung function more quickly.^80-82 A dose of 40 mg oral prednisolone per day (or equivalent) for 5-10 days is recommended. Carefully look for tuberculosis by sputum examination and chest radiograph before starting corticosteroids.

Controlled oxygen therapy can be administered at low flow rates (preferably with a Venturi mask) with monitoring for features of CO₂ retention.⁸³ Chest physiotherapy, inhaled corticosteroids and mucolytic agents are generally not useful in the management of acute exacerbations.

Patients with the following features should be hospitalized for further management:

• Marked increase in intensity of symptoms, such as sudden development of resting dyspnea
• Onset of new physical signs (e.g. cyanosis, drowsiness, confusion, flaps, peripheral edema)
• Failure of exacerbation to respond to initial medical management
• Significant co morbidities such as diabetes or associated cardiac disease
• Newly occurring arrhythmias
• Diagnostic uncertainty