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A Review of the GOLD Guidelines for the Diagnosis and Treatment of Patients With COPD: Managing COPD Exacerbations


Managing COPD Exacerbations

Exacerbations of COPD are typically defined as acute changes in symptoms (cough, dyspnoea and sputum production) beyond what is considered normal variability in a patient.[1,6] They occur in the natural course of COPD and often require modifications in COPD treatment regimens and hospitalisation for effective management.[1,6] COPD exacerbations have a negative impact on patient symptoms, disrupt daily activities, often contribute to diminished QoL, and have been associated with increased mortality rates.[108,109] In one study, patients with COPD experienced an average of two exacerbations of COPD per year, with more than one-third of patients experiencing three or more exacerbations annually.[12] In a prospective 5-year study designed to determine the prognostic value of rates of severe acute exacerbations that required hospitalisation (independent of the severity of COPD), Soler-Cataluna et al.[109] found that mortality risk increased with the number of acute exacerbations of COPD experienced by a patient. The highest mortality rate was seen in patients who experienced three or more exacerbations during the study. Their results also suggested that the risk of death increases with the severity of exacerbations independent of the stage of COPD. Effective management and reduction or elimination of exacerbations should therefore be a primary goal of any treatment plan.[1]

Although the cause of approximately one-third of severe COPD exacerbations is unknown, they are commonly associated with infections of the tracheobronchial tree and with air pollution.[110] Patients who experience acute exacerbations commonly present with increased breathlessness, wheezing, tightness in the chest, increased cough sputum production, change in colour and tenacity of sputum, and fever. Patients may also experience tachycardia, tachypnoea, malaise, insomnia, fatigue, depression and confusion. Before the onset of an exacerbation, patients may have decreased exercise tolerance and fever.[1] Depending on the severity of the exacerbation, referral to a specialist or hospitalisation should be considered. Some exacerbations, however, can be managed through hospital-at-home care by a skilled healthcare professional. Although exacerbations may be treated effectively at home,[111] there are unresolved issues of differentiating when at-home care is insufficient and when hospitalisation is required.[1]

Generally, at-home management consists of increasing the doses and/or frequency of the patient's current short-acting bronchodilator therapy. Of the short-acting agents, SABAs are the preferred first-choice therapeutic agents. An inhaled anticholinergic agent, if not already used, may be added until symptoms improve.[1] An antibiotic should be prescribed when increased dyspnoea is clearly associated with sputum purulence.[1,6,112] The addition of short-term OCS therapy to bronchodilator therapy during COPD exacerbations should also be considered for patients with an FEV1<50%, although some physicians prescribe OCS if they feel the exacerbation is severe enough to warrant their use, regardless of FEV1. Combination therapy with OCS and a bronchodilator has been shown to shorten recovery time, restore lung function and reduce the risk for relapse.[1,113]

Although most patients who experience acute exacerbations are not at imminent risk of dying, patients with severe underlying COPD often require hospitalisation to effectively manage their exacerbations. Criteria that would necessitate hospitalisation include marked intensity of symptoms, severe COPD, failure of response to initial treatment, significant comorbidities, advanced age and inadequate home support.[1] Intensive care unit admission may be warranted when patients have severe dyspnoea that fails to respond to treatment, diminished mental status, persistent or worsening hypoxaemia and hypercapnia despite supplemental oxygen and NIPPV, and haemodynamic instability.[1]

During COPD exacerbations that require hospitalisation, oxygen therapy is central to treatment and should be initiated immediately.[1] SABAs are the preferred bronchodilators for the treatment of exacerbations. If response is inadequate or too slow, addition of an inhaled anticholinergic is recommended.[1] Methylxanthines (theophylline and aminophylline) may also be considered to treat more severe exacerbations, although such treatment remains controversial and caution should be exercised because of treatment-associated adverse events.[1,114] Their use should be considered when short-acting bronchodilators do not produce adequate response.[1] Treatment with oral or intravenous corticosteroids in addition to other therapies may also be an option, because OCSs have been demonstrated to shorten exacerbations, although the benefits are short lived[115] and prolonged treatment with these agents will not improve clinical efficacy and may only increase the risk for adverse events.[1] Initiation of antibiotic treatment during COPD exacerbations is indicated in patients with increased dyspnoea, sputum purulence and sputum volume.[1] Antibiotics may reduce mortality, treatment failure and sputum purulence.[116] Ventilatory support may be implemented for patients with severe COPD and acute respiratory failure to decrease morbidity and in-hospital mortality and provide symptom relief.[1] A suggested management algorithm for exacerbations is provided in Figure 3. Although the optimal duration of hospitalisation for an exacerbation has yet to be established, follow-up assessments are recommended to take place approximately 4–6weeks following the patient's discharge from the hospital.[1]

Figure 3. (click image to zoom) Suggested management algorithm for acute exacerbations of chronic obstructive pulmonary disease (COPD). This figure has been adapted by Leonard Fromer, MD with permission from the GOLD 2006 guidelines[1]

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