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Sarah Marshall, PhD, MRPharmS, is a freelance pharmaceutical
writer from Aberdeenshire
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Exacerbations of COPD
General advice |
Science Photo Library
In pneumonia, lung tissue fills with fluid, which replaces air and
causes the lung to become solid |
SUMMARY
An estimated 17 per cent of all GP consultations are for acute respiratory
infections, accounting for more GP visits annually than any other condition.
They occur primarily in the autumn and winter, with pre-school children,
people over 65 years of age, smokers, alcoholics and those with serious
co-morbidity or immunosuppression being particularly susceptible.
“Chest
infection” is a broad term that covers various conditions, ranging
from mild and self-limiting ones to severe, potentially fatal disease.
Adult chest infections treated in the community can be divided into three
categories:
• acute bronchitis
• community-acquired pneumonia (CAP)
• exacerbations of chronic obstructive pulmonary disease (COPD; see Panel 1,
p476).
Acute bronchitis is a transient inflammation of the trachea and major
bronchi as a result of infection, which often follows a cold or influenza.
In contrast, pneumonia usually involves acute inflammation further down
the respiratory tract — there is intense infiltration of inflammatory
cells into and around the alveoli and terminal bronchioles.
The resulting
inflammation and production of exudate lead to sections of the lung
or even entire lobes becoming solid (a result of fluid filling the tissue,
losing their usual spongy texture. Either or both of the lungs may
be
affected.
About 44 cases of acute bronchitis per 1,000 adult population occur
annually in the UK. CAP is less common, with an annual incidence of
five to 11
per 1,000 adults but it is more serious, resulting in an estimated
83,000 hospital admissions each year. Full article PDF 80K
Panel 1: Exacerbations of COPD
Chronic obstructive pulmonary disease (COPD) is
the name now used for a group of conditions, including those once
referred to as
chronic bronchitis and emphysema, and is usually the result of
exposure to cigarette smoke. There are about 900,000 people diagnosed
with COPD in the UK and 26,000 people die from it each year.
COPD is a chronic condition that progresses slowly. When stable,
it is characterised by airflow obstruction that remains at a constant
level (ie, over several months). Symptoms can include difficulty
breathing, chronic cough (ie, longer than eight weeks), regular
sputum production and wheeze.
An exacerbation of COPD is usually
diagnosed
if a patient has a sudden onset of worsening cough, increased breathlessness
and a change in sputum colour and an increase in the volume of
sputum being produced. There may be additional symptoms, such
as a cold
and sore throat, increased wheeze, chest tightness, reduced exercise
tolerance, fluid retention, increased fatigue and acute confusion.
Chest
pain and fever do not usually occur and suggest a different cause.
The precise role that infection plays in exacerbations of COPD
is unclear because the sputum of sufferers may be colonised on
a permanent
basis. Up to 30 per cent of cases may be viral and as much as 50
per cent may be bacterial. The most common pathogens are Haemophilus
influenzae, Streptococcus pneumoniae, and Pseudomonas
aeruginosa.
However, at least a third of exacerbations may be due to a non-infective
cause.
Repeated exacerbations of COPD lead to a poor prognosis, so they
should be treated as effectively and quickly as possible. In some
cases, exacerbations may be managed by increasing the dose or frequency
of existing short-acting bronchodilator therapy or by prescribing
additional bronchodilators. If breathlessness is severe enough
to interfere with daily activities, a short course of oral prednisolone
should be considered. Oxygen therapy may be necessary to increase
arterial oxygen saturations.
If the patient’s sputum is more purulent than usual or he
or she is showing signs of pneumonia, the exacerbation is also
treated
with antibiotics. Amoxicillin, a tetracycline or a macrolide are
used as first-line treatment. If the infection fails to respond,
treatment with one of the alternative first-line options or co-amoxiclav
would be appropriate. The recommended duration of treatment is
five to seven days.
Patients with low blood pressure, low oxygen
saturation
or raised respiratory rate, whose condition is deteriorating
or who are otherwise not coping at home should be admitted to hospital.
To allow rapid treatment of exacerbations patients with COPD
may be given a course of antibiotics to be kept at home, along
with
instructions on when to take them. Preventive measures can reduce
the likelihood
of an exacerbation. Those who suffer more than two exacerbations
a year may be prescribed long-acting beta2-agonists,
tiotropium, or inhaled corticosteroids. Use of mucolytic agents,
such as carbocisteine,
is controversial but may have some value in reducing the frequency
of chest infections in this group.
In addition to the general advice applicable to people with chest
infections (see Panel 2), pharmacists
can support patients with COPD by counselling them on the appropriate
use of inhalers, spacers
or
nebulisers and encouraging compliance with antibiotic and oral
corticosteroid therapy.
A national service framework for COPD is expected next year. |
Panel 2: General advice
General
• Rest and drink plenty of fluids
• Paracetamol or ibuprofen can ease aches and fever
• Contact the GP if new symptoms develop or existing symptoms
get worse For acute bronchitis
• Cough may persist for up to four weeks
• Cough
medicines are unlikely to help (see PJ,
20 January 2007, pp85–8)
• In people who are otherwise healthy, antibiotics are unlikely
to help (even in bacterial bronchitis, they may not speed recovery
and can cause side effects)
For community-acquired pneumonia
• It is important to take antibiotics as prescribed
• If symptoms do not rapidly improve (the Health Protection Agency
suggests within 48 hours) the patient should tell his or her GP
because a different antibiotic or a stay in hospital may be required |
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The
Pharmaceutical Journal