Acute exacerbation of chronic obstructive pulmonary disease
Summary
Definition
History and exam
Key diagnostic factors
- dyspnoea
- cough
- increased sputum purulence and volume
- wheeze
- chest tightness/chest pain
- tachypnoea
- tachycardia
- risk factors
- cor pulmonale
Other diagnostic factors
- signs of respiratory failure
- fever
- gastro-oesophageal reflux and/or swallowing dysfunction
Risk factors
- bacterial infection
- gastro-oesophageal reflux and/or swallowing dysfunction
- viral infection
- pollutants
- atypical bacterial infection
- change in weather
Diagnostic investigations
1st investigations to order
- arterial blood gas (in hospital)
- pulse oximetry (in hospital and in the community)
- ECG (in hospital and in the community if available)
- FBC with platelets (in hospital)
- urea, electrolytes, and creatinine (in hospital)
- CRP (in hospital)
- CXR (in hospital)
- sputum microscopy, culture, and Gram stain (in hospital)
- vitamin D (in hospital or in the community)
Investigations to consider
- blood cultures
- respiratory virus diagnostics
- cardiac troponin
- serum theophylline level
- pro-brain natriuretic peptide (BNP)
- CT scan of chest
- spirometry
Treatment algorithm
Contributors
Expert advisers
Jonathan Bennett, MD
Honorary Professor of Respiratory Sciences
University of Leicester
Respiratory Consultant
Glenfield Hospital
Leicester
UK
Biography
JB is Chair of the British Thoracic Society (BTS). He is also deputy medical director RCP Invited service Reviews, and speaker at National Society (eg., BTS), Primary Care respiratory Society, Society Cardiothoracic Surgeons meetings.
Disclosures
JB declares that he has no competing interests.
Richard Russell,
Specialty Registrar in Respiratory Medicine
Glenfield Hospital
Leicester
UK
Disclosures
RJR received sponsorship from AstraZeneca to attend a conference, May 2018 (covering travel, accommodation, and conference fee).
Acknowledgements,
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:
Carolyn L. Rochester MD
Associate Professor
Yale University School of Medicine
New Haven
VA Connecticut Healthcare System
West Haven
CT
Richard A. Martinello MD
Associate Professor
Yale University School of Medicine
New Haven
Veterans Health Administration
Office of Public Health
West Haven
CT
Disclosures
CLR serves on the COPD scientific advisory board for GlaxoSmithKline Pharmaceuticals but has no competing interests pertaining to this publication. RAM declares that he has no competing interests.
Peer reviewers
Carlos Echevarria,
Consultant Respiratory Physician
Royal Victoria Infirmary
Newcastle upon Tyne
UK
Disclosures
CE declares that he has no competing interests.
Editors
Emma Quigley,
Section Editor, BMJ Best Practice
Disclosures
EQ declares that she has no competing interests.
Tannaz Aliabadi-Oglesby,
Lead Section Editor, BMJ Best Practice
Disclosures
TAO declares that she has no competing interests.
Julie Costello,
Comorbidities Editor, BMJ Best Practice
Disclosures
JC declares that she has no competing interests.
Adam Mitchell,
Drug Editor, BMJ Best Practice
Disclosures
AM declares that he has no competing interests.
Expert advisers: comorbidities
Martyn Patel, BMBcH, FRCP, MA
Consultant, Older People's Medicine
Norfolk and Norwich University Hospitals
NHS Foundation Trust
Norwich
UK
Disclosures
MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare, virtual conference in November 2020 for which he received no fee. MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018).
Andrew Lewington, BSc (Hons), MBBS, MEd, MD, FRCP
Consultant Renal Physician
Honorary Associate Professor
Nephrology Department
Leeds Teaching Hospitals NHS Trust
Leeds
UK
Disclosures
AL is Associate Clinical Director of NIHR Leeds In-Vitro Diagnostics Co-operative, Co-Chair of UK Kidney Research Consortium Renal Clinical Study Group, Member of Kidney Research UK Research Grant Committee, Committee Member of NICE Kidney Injury Clinical Guideline Update 2018-20, Committee Member of NICE Diagnostic Assessment for Point of Care Creatinine Testing 2018-19. AL attended the Acute Dialysis Quality Initiative Meeting in San Diego 2018 (accommodation expenses); AL was a speaker at the AKI & CRRT Conference in San Diego 2019 (travel and accommodation expenses), the AKI Conference in Coventry 2019 (travel expenses), and the NIHR AKI and Sepsis Meeting in Leeds 2019 (no expenses).
Martin Cowie, MD, MSc, FRCP, FRCP (Ed), FESC, FHFA, FACC
Professor of Cardiology
Imperial College London (Royal Brompton Hospital)
London
UK
Disclosures
MC is chair of the European Society of Cardiology Digital Health Committee and a trustee of the Atrial Fibrillation Society. He has previously been a non-executive director of the National Institute for Health and Care Excellence. MC provides consultancy advice to AstraZeneca, Servier, Abbott, Medtronic, Boston Scientific, & Genomics PLC. MC declares that none of these interests is directly related to topics advised on for this project.
Rachael Evans, MBChB, FRCP (UK), PhD
Associate Professor (Clinical)
University of Leicester
Honorary Consultant Respiratory Physician
Glenfield Hospital
Leicester
UK
Disclosures
RAE has given lectures for non-promotional industry-led sessions on COPD management, including for GSK and Chiesi for individual payment and travel expenses totalling <£2,000.
Gerry Rayman, MD, FRCP
Consultant Physician and Head of Service
Diabetes and Endocrine Centre and the Diabetes Research Unit
Ipswich Hospitals NHS Trust
Ipswich
UK
Disclosures
GR has been paid for advisory board meetings with the following companies: Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Bayer. GR has received lecture fees from Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Novonordisk, Napp Pharmaceuticals Ltd.
Sotiris Posporelis, MD, MRCPsych
Consultant Liaison Neuropsychiatrist
King’s College Hospital
South London and Maudsley NHS Foundation Trust
Honorary Senior Clinical Lecturer
Institute of Psychiatry, Psychology & Neuroscience
King’s College London
London
UK
Disclosures
SP declares that he has no competing interests.
Hamish McAuley, MBBS, BSc, MRCP
Clinical Research Fellow
Specialist Registrar (ST5)
Department of Respiratory Sciences
University of Leicester
Respiratory Biomedical Research Unit
Glenfield Hospital
Leicester
UK
Disclosures
HM declares that he has no competing interests.
Asangaedem Akpan, MPH, FRC
Consultant Geriatrician
Liverpool University Hospitals NHS Foundation Trust
Visiting Professor
University of Cumbria
Carlisle
Honorary Clinical Associate Professor
University of Liverpool
Liverpool
UK
Disclosures
AA declares that he has no competing interests.
Peer reviewers: comorbidities
Martyn Patel, BMBcH, FRCP, MA
Consultant, Older People's Medicine
Norfolk and Norwich University Hospitals
NHS Foundation Trust
Norwich
UK
Disclosures
MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare virtual conference in November 2020, for which he received no fee. MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018).
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