Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Exacerbations are episodes of increased respiratory and sometimes systemic symptoms in patients with underlying chronic obstructive pulmonary disease (COPD). They reflect increased airway inflammation usually induced by bacterial and/or viral tracheobronchial infection. These episodes are a major contributor to the morbidity and, in advanced disease, to the mortality associated with COPD. A careful clinical evaluation with selected application of diagnostic tests should be followed by individualized management including supportive care, bronchodilators, antibiotics, and corticosteroids. Exacerbations can be partially prevented with current treatment of COPD. Our understanding of exacerbation mechanisms has evolved and led to better outcomes and greater use of effective preventative measures.

A 72-year-old female who was diagnosed with COPD a year earlier presents for an acute care office visit. She has not smoked for the last 10 years but did smoke a pack of cigarettes per day for 40 years. She had spirometry performed a year ago because of gradually increasing dyspnea on exertion demonstrating moderate airflow obstruction. She was started on an inhaled long-acting muscarinic antagonist to be used once daily and a short-acting beta-agonist inhaler to be taken as needed. She states that she was doing well until the past 5 days, during which she has had an increase in her dyspnea accompanied by cough and sputum that is yellow-green in color. She feels more fatigued and has not been able to sleep well but denies fever, pleuritic chest pain, or hemoptysis. Her other medical conditions include hypertension, a myocardial infarction, and congestive heart failure.

On examination she is not in acute distress and her vital signs are stable. Oxygen saturation by pulse oximetry on room air is 91%. Lung examination demonstrates decreased air entry and scattered rales and rhonchi in both lower lobes. Cardiac exam is unremarkable, and there is no evidence of decompensation of her congestive heart failure.

COMMENT: The clinical presentation is compatible with an exacerbation of COPD. A careful clinical evaluation was conducted to exclude other reasons for the worsening respiratory symptoms, such as congestive heart failure, pneumonia, and pulmonary embolism. No further diagnostic testing was required, and there was no indication for hospitalization. Purulent sputum indicated a need for a short course of oral antibiotics. Short-acting bronchodilator therapy was recommended at increased frequency, as well attention to adequate hydration and nutrition. The patient was instructed to seek additional care if there was no improvement within 48 hours or there was worsening at any point.