Abstract

COPD is a progressive debilitating lung condition the clinical course of which is punctuated by acute severe increases in symptoms (exacerbations). These can be life threatening and are a considerable cause of morbidity and mortality as well as frequently requiring hospital admission. The aims of treatment are to prevent attacks through vaccination, smoking cessation, appropriate medication, the provision of pulmonary rehabilitation and also patient education. During an attack treatment should be provided in the most suitable place for the individual (home or hospital) and consists of an accurate diagnosis, clinical assessment and the provision of bronchodilators, corticosteroids and antibiotics where appropriate. More severe attacks necessitating hospital assessment and admission may require ventilatory support and even intensive care. Where possible patients should be involved in decision making, particularly with regard to treatment and a possible ceiling of care.
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References

1. Silverman EK. Exacerbations in chronic obstructive pulmonary disease: do they contribute to disease progression? Proc Am Thorac Soc 2007; 4(8): 586–590.
2. Schermer TR, Saris CG, van den Bosch WJ, et al. Exacerbations and associated healthcare cost in patients with COPD in general practice. Monaldi Arch Chest Dis 2006; 65(3): 133–140.
3. Price LC, Lowe D, Hosker HS, et al. UK National COPD Audit 2003: Impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation. Thorax 2006; 61(10): 837–842.
4. O‘Reilly JF, Williams AE, Rice L. Health status impairment and costs associated with COPD exacerbation managed in hospital. Int J Clin Pract 2007; 61(7): 1112–1120.
5. Hurst JR, Wedzicha JA. The biology of a chronic obstructive pulmonary disease exacerbation. Clin Chest Med 2007; 28(3): 525–36, v.
6. Hurst JR, Perera WR, Wilkinson TM, et al. Systemic and upper and lower airway inflammation at exacerbation of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2006; 173(1): 71–78.
7. Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2007; 176(6): 532–555.
8. Anthonisen NR, Manfreda J, Warren CP, et al. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 1987; 106(2): 196–204.
9. Sapey E, Stockley RA. COPD exacerbations . 2: aetiology. Thorax 2006; 61(3): 250–258.
10. Wedzicha JA, Seemungal TA. COPD exacerbations: defining their cause and prevention. Lancet 2007; 370(9589): 786–796.
11. Wedzicha JA. Role of viruses in exacerbations of chronic obstructive pulmonary disease. Proc Am Thorac Soc 2004; 1(2): 115–120.
12. Celli BR, Barnes PJ. Exacerbations of chronic obstructive pulmonary disease. Eur Respir J 2007; 29(6): 1224–1238.
13. Donaldson GC, Seemungal T, Jeffries DJ, et al. Effect of temperature on lung function and symptoms in chronic obstructive pulmonary disease. Eur Respir J 1999; 13(4): 844–849.
14. British Thoracic Society/NICE Guidelines for Chronic Obstructive Pulmonary Disease. 1-2-2004. Ref Type: Internet Communication
15. Halpin D. NICE guidance for COPD. Thorax 2004; 59(3): 181–182.
16. van der Valk P, Monninkhof E, van der Palen J, et al. Effect of discontinuation of inhaled corticosteroids in patients with chronic obstructive pulmonary disease: the COPE study. Am J Respir Crit Care Med 2002; 166(10): 1358–1363.
17. Aaron SD, Vandemheen KL, Hebert P, et al. Outpatient oral prednisone after emergency treatment of chronic obstructive pulmonary disease. N Engl J Med 2003; 348(26): 2618–2625.
18. Chetty M, MacKenzie M, Douglas G, et al. Immediate and early discharge for patients with exacerbations of chronic obstructive pulmonary disease: is there a role in “real life”? Int J Chron Obstruct Pulmon Dis 2006; 1(4): 401–407.
19. Cotton MM, Bucknall CE, Dagg KD, et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Thorax 2000; 55(11): 902–906.
20. 20 Ram FS, Wedzicha JA, Wright J, et al. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2003; (4): CD003573.
21. Brochard L, Mancebo J, Elliott MW. Noninvasive ventilation for acute respiratory failure. Eur Respir J 2002; 19(4): 712–721.
22. Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet 2000; 355(9219): 1931–1935.
23. Bott J, Carroll MP, Conway JH, et al. Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease. Lancet 1993; 341(8860): 1555–1557.
24. Wildman MJ, Sanderson C, Groves J, et al. Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study. BMJ 2007; 335(7630): 1132.
25. Tuggey JM, Plant PK, Elliott MW. Domiciliary non-invasive ventilation for recurrent acidotic exacerbations of COPD: an economic analysis. Thorax 2003; 58(10): 867–871.
26. Intermediate care--Hospital-at-Home in chronic obstructive pulmonary disease: British Thoracic Society guideline Thorax 2007; 62(3): 200–210.
27. Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2005; (3): CD000356.
28. Quantrill SJ, Lowe D, Hosker HS, et al. Survey of early discharge schemes from the 2003 UK National COPD Audit. Respir Med 2007; 101(5): 1026–1031.
29. Davies L, Wilkinson M, Bonner S, et al. “Hospital at home” versus hospital care in patients with exacerbations of chronic obstructive pulmonary disease: prospective randomised controlled trial. BMJ 2000; 321(7271): 1265–1268.
30. Skwarska E, Cohen G, Skwarski KM, et al. Randomized controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease. Thorax 2000; 55(11): 907–912.
31. Cotton MM, Bucknall CE, Dagg KD, et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Thorax 2000; 55(11): 902–906.
32. Ram FS, Wedzicha JA, Wright J, et al. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2003; (4): CD003573.
33. Gravil JH, Al Rawas OA, Cotton MM, et al. Home treatment of exacerbations of chronic obstructive pulmonary disease by an acute respiratory assessment service. Lancet 1998; 351(9119): 1853–1855.
34. Nannini LJ, Cates CJ, Lasserson TJ, et al. Combined corticosteroid and longacting beta-agonist in one inhaler versus inhaled steroids for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2007; (4): CD006826.
35. Nannini L, Cates CJ, Lasserson TJ, et al. Combined corticosteroid and long-acting beta-agonist in one inhaler versus placebo for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2007; (4): CD003794.
36. Mallia P, Johnston SL. Influenza infection and COPD. Int J Chron Obstruct Pulmon Dis 2007; 2(1): 55–64.
37. Burge PS. Prevention of exacerbations: how are we doing and can we do better? Proc Am Thorac Soc 2006; 3(3): 257–261.