**3. Initial evaluation of an exacerbation**

There are two main steps in the evaluation of a COPD exacerbation. The first step is the determination of severity of the disease that will guide the physician about the treatment approach and hospitalization decision. The second step is the identification of the etiologic cause and decide whether to initiate antibiotherapy or not.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) classifies COPD exacerbations as mild, moderate or severe, based on the intensity of the medical intervention required to control the patient's symptoms (Table 1)(Rabe et al. 2007).


+: probably doesn' t exist, ++: probably exists, +++: strongly may exist, ICU: intensive care unit

Table 1. Classification of COPD exacerbations

Patients who are known to have COPD are defined as an exacerbation when they are admitted to the emergency departments with increased dyspnea during fall and winter. The main issue is the underestimation of non-infectious causes such as pulmonary embolism, pleural effusion, pneumothorax, thoracic traumas, inappropriate use of sedatives, narcotics and beta blockers, arrhythmias, cardiac failure or problems in the use of long term oxygen therapy. Therefore, in a COPD patient with increased dyspnea, first the diagnosis of exacerbation should be established correctly and then the etiology should be identified as

Potentially pathogen bacteria are identified in 30% of sputum cultures in mild exacerbations, while this rate can be up to 70% in severe exacerbations in patients who need

There are two main steps in the evaluation of a COPD exacerbation. The first step is the determination of severity of the disease that will guide the physician about the treatment approach and hospitalization decision. The second step is the identification of the etiologic

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) classifies COPD exacerbations as mild, moderate or severe, based on the intensity of the medical intervention required to control the patient's symptoms (Table 1)(Rabe et al. 2007).

> **Moderate**  (hospital treatment)

No ++ +++

**Severe**  (ICU treatment)

(home treatment)

Comorbidity + +++ +++

history + +++ +++

COPD stage Mild/Moderate Moderate/Severe Severe

Change in neurologic status No No Yes

failure No ++ +++

despite drug therapy No ++ +++

+: probably doesn' t exist, ++: probably exists, +++: strongly may exist, ICU: intensive care unit

Hemodynamic status Stable Stable Stable/Unstable

ventilatory support (Sapey Stockley 2006; Siddiqi Sethi 2008).

cause and decide whether to initiate antibiotherapy or not.

**3. Initial evaluation of an exacerbation** 

**Clinical history Mild** 

infectious or non-infectious.

Frequent exacerbation

Accessory respiratory muscle use, cyanosis, paradoxal breathing, cyanosis, tachypnea

Symptoms of right heart

Persistence of symptoms

Table 1. Classification of COPD exacerbations

Another classification approach is suggested by Anthonisen and colleagues (Anthonisen et al. 1987). According to this approach, severe exacerbations requiring antibiotheraphy are characterized by the presence of increase in all of the 3 criteria: dyspnea, sputum production and sputum purulence. Moderate exacerbations show only the 2 of these criteria, while in mild exacerbations, only one of these criteria is present with a recent history of upper airway infection or fever or symptoms like wheezing, cough, tachypnea and tachycardia.

Diagnostic evaluation of a suspected COPD exacerbation varies whether the patient will be treated in the hospital or at home. Routine sputum culture evaluation is not recommended for mild exacerbations. In case of a severe exacerbation, oxygen saturation must be measured by a pulse oxymeter. Patients who are referred to a hospital must be evaluated by advanced diagnostic tests such as arterial blood gas analysis, chest x-ray, sputum gram staining and cultures, electrocardiography and blood drug levels if possible (Table 2).


\*: blood cell count, serum electrolytes, urea, creatinine, liver function tests.

\*\*: theophylline, warfarin, carbamazepine, digoxin

†: One third of dyspnea in chronic lung disease may be attributable to congestive heart failure.

‡: Cardiac ischemia (myocardial infarction is underdiagnosed in patients with COPD).

Table 2. Diagnostic evaluation of patients with suspected COPD exacerbation

About 50% of COPD exacerbations are not reported to physicians(Seemungal et al. 2000). This suggests that half of the exacerbations are mild and do not require hospitalization. Indications for hospitalization of a patient with COPD exacerbation are as follows:


Management of Acute Exacerbations 295

\*Hospitalization in the last one month, frequent antibiotic use in the last one year, exacerbation causing severe respiratory failure, isolation of *P. Aeruginosa* in the sputum culture during stable state or prior

Table 3. Antibiotherapy options in infectious exacerbations of COPD

exacerbations.

