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Key Points

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  • Respiratory infections are responsible for most acute exacerbations of chronic obstructive pulmonary disease (COPD).

  • Beta-adrenergic agonists and anticholinergic drugs remain the primary bronchodilators and are most effective when used together.

  • Steroids should be given to nearly all patients presenting to the emergency department (ED) with COPD exacerbations, and ongoing therapy should be prescribed for those patients who are discharged.

  • Antibiotics are an important adjunct to therapy, although their use should be guided by the patient's signs and symptoms.

  • Noninvasive ventilation is a critical component of therapy that is best used early in the ED course to avoid the need for intubation.

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Introduction

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Chronic obstructive pulmonary disease (COPD) is defined as an illness characterized by irreversible, progressive airway obstruction that is associated with inflammatory pulmonary changes. It is extraordinarily common, and patients with exacerbations of COPD will continue to inundate emergency departments (EDs) in search of respiratory relief. In the United States, COPD is the fourth most common cause of death.

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The use of the term COPD encompasses patients with chronic bronchitis and emphysema, as well as those patients with asthma who have a component of irreversible airflow obstruction. Airflow obstruction is the end result of a process that begins with particulate air pollution exposure (usually from tobacco smoke). Particulate exposure initiates a cascade of events, including airway inflammation and narrowing of the small airways, as well as airway destruction and remodeling in the setting of diminished repair mechanisms and fibrosis, resulting in fixed airflow obstruction and air trapping. Although there are clearly pathophysiologic differences between these groups, their evaluation and treatment is largely the same.

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A COPD exacerbation is an event characterized by a worsening of the patient's respiratory symptoms beyond the normal day-to-day variation. Typically, this involves one or all of the following: worsening dyspnea, increased sputum as well as a change in the character of sputum, and an increase in the frequency and severity of cough.

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Clinical Presentation

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History
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The critical aspects of the history in evaluating patients with dyspnea due to a presumed COPD exacerbation are to establish the patient's baseline function, assess the severity of the exacerbation, determine a cause, and rule out disorders that may mimic a COPD exacerbation. Most patients experiencing a COPD exacerbation present with complaints of increased dyspnea in the setting of a recent onset respiratory infection (ie, upper respiratory infection). As a result, they may complain of a productive or sometimes a nonproductive cough that differs from their baseline cough, rhinorrhea and nasal congestion, and fevers and chills, as well as the constitutional symptoms that frequently accompany systemic illness. Most such patients are chronically ill and often quite frail, so the key to determining the severity of the exacerbation is establishing their baseline health. To do this, it helps to ascertain their oxygen use, their current treatment regimen, ...

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