Acute exacerbation of chronic obstructive pulmonary disease
Encyclopedia
An acute exacerbation of COPD is a sudden worsening of COPD
Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease , also known as chronic obstructive lung disease , chronic obstructive airway disease , chronic airflow limitation and chronic obstructive respiratory disease , is the co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing diseases...

 symptoms (shortness of breath, quantity and color of phlegm
Phlegm
Phlegm is a liquid secreted by the mucous membranes of mammalians. Its definition is limited to the mucus produced by the respiratory system, excluding that from the nasal passages, and particularly that which is expelled by coughing . Phlegm is in essence a water-based gel consisting of...

) 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 worsening of gas transfer.

In absence of concomitant presence of emphysema
Emphysema
Emphysema is a long-term, progressive disease of the lungs that primarily causes shortness of breath. In people with emphysema, the tissues necessary to support the physical shape and function of the lungs are destroyed. It is included in a group of diseases called chronic obstructive pulmonary...

, the underlying condition may be classified as chronic bronchitis
Chronic bronchitis
Chronic bronchitis is a chronic inflammation of the bronchi in the lungs. It is generally considered one of the two forms of chronic obstructive pulmonary disease...

 alone, and the exacerbations are then termed "acute exacerbations of chronic bronchitis
Acute exacerbations of chronic bronchitis
Acute exacerbations of chronic bronchitis are episodes of difficulty in breathing in a person with chronic bronchitis.In concomitant presence of emphysema, the underlying condition can be classified as chronic obstructive pulmonary disease , and the exacerbations termed "acute exacerbation of...

" (AECB), and shares many characteristics with that of acute exacerbation of COPD. As COPD progresses, exacerbations tend to become more frequent, the average being about three episodes per year.

Causes

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 infections.
  • Air pollution
    Air pollution
    Air pollution is the introduction of chemicals, particulate matter, or biological materials that cause harm or discomfort to humans or other living organisms, or cause damage to the natural environment or built environment, into the atmosphere....

  • Pulmonary embolism
    Pulmonary embolism
    Pulmonary embolism is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream . Usually this is due to embolism of a thrombus from the deep veins in the legs, a process termed venous thromboembolism...

  • Failing to follow a Drug therapy program, e.g. improper use of an Inhaler
    Inhaler
    An inhaler or puffer is a medical device used for delivering medication into the body via the lungs. It is mainly used in the treatment of asthma and Chronic Obstructive Pulmonary Disease . Zanamivir , used to treat influenza, must be administered via inhaler...



In one-third of all COPD exacerbation cases, the cause cannot be identified.

Although the condition of a patient with COPD can become exacerbated by many other factors as well, the scope is generally restricted to the ones that cause the symptoms below.

Signs and symptoms

For the most part, symptoms of a COPD exacerbation will remain of the same variations experienced in COPD patients, but will be worsened due to environmental and other factors. These may include, but are not limited to: an increased amount of cough
Cough
A cough is a sudden and often repetitively occurring reflex which helps to clear the large breathing passages from secretions, irritants, foreign particles and microbes...

 and sputum
Sputum
Sputum is mucus that is coughed up from the lower airways. It is usually used for microbiological investigations of respiratory infections....

 productions from usual day-to-day variations. This may be accompanied by a change in the usual appearance of the sputum produced. Other symptoms include increased wheezing, fever
Fever
Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...

 and a sensation of tightness in the chest.

An abrupt worsening in COPD symptoms may cause rupture of the airways in the lungs, which in turn may cause a spontaneous pneumothorax
Pneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...

.

Prevention

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 agonist
Long acting beta-adrenoceptor agonist
Long-acting beta-adrenoceptor agonists are usually prescribed for moderate to severe persistent asthma patients or patients with chronic obstructive pulmonary disease...

s (LABAs), long-acting anticholinergics, inhaled corticosteroids and low-dose theophylline have all been shown to reduce the frequency of COPD exacerbations.

Oxygen

High flow oxygen may be harmful in those with an acute exacerbation of COPD. In the prehospital environment those give high flow O2 rather that titrating their O2 sats to 88% to 92% had worse outcomes.

Medications

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 recovery. The iv and oral forms of steroids have been found to be equivalent. Antibiotics are often used but will only help if the exacerbation is due to an infection. Antibiotics are indicated when a patient notes increased sputum production, purulent sputum, increased dyspnea, has an elevated white count, or is febrile. Examples of first-line antibiotics are amoxicillin
Amoxicillin
Amoxicillin , formerly amoxycillin , and abbreviated amox, is a moderate-spectrum, bacteriolytic, β-lactam antibiotic used to treat bacterial infections caused by susceptible microorganisms. It is usually the drug of choice within the class because it is better absorbed, following oral...

, doxycycline
Doxycycline
Doxycycline INN is a member of the tetracycline antibiotics group, and is commonly used to treat a variety of infections. Doxycycline is a semisynthetic tetracycline invented and clinically developed in the early 1960s by Pfizer Inc. and marketed under the brand name Vibramycin. Vibramycin...

 and co-trimoxazole
Co-trimoxazole
Trimethoprim/sulfamethoxazole or co-trimoxazole is a sulfonamide antibiotic combination of trimethoprim and sulfamethoxazole, in the ratio of 1 to 5, used in the treatment of a variety of bacterial infections.The name co-trimoxazole is the British Approved Name, and has been marketed worldwide...

.

Mechanical ventilation

Severe exacerbations can require hospital care where treatments such as oxygen and mechanical ventilation
Mechanical ventilation
In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be assisted by a physician, respiratory therapist or other suitable person compressing a bag or set of bellows...

may be required.

Ambiguous definitions

The definition of a COPD exacerbation is commonly described as "lost in translation," 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.
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