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Exacerbations of chronic obstructive pulmonary disease

¹ Caritas St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA. ² National Heart and Lung Institute, Imperial College, London, UK.

CORRESPONDENCE: P. J. Barnes, Airway Disease Section, National Heart and Lung Institute, Dovehouse Street, London SW3 6LY, UK. Fax: 44 2073515675. E-mail: p.j.barnes{at}imperial.ac.uk

Keywords: Bacterial infection, exacerbation, health status, inflammation, viral infection

Received: August 23, 2006
Accepted February 15, 2007

Exacerbations of chronic obstructive pulmonary disease are of major importance in terms of their prolonged detrimental effects on patients, the acceleration in disease progression and high healthcare costs.

There is still debate about how exacerbations should be defined and graded, and their mechanisms are poorly understood. The major causal agents are either bacteria or viral infections, or a combination of the two. Noninfective causes include air pollution and pulmonary embolus but, in some patients, no cause is identified.

Exacerbations represent an increase in the inflammation that is present in the stable state, with increased numbers of inflammatory cells (particularly neutrophils), cytokines, chemokines and proteases in the airways, and increased concentrations of certain cytokines and C-reactive protein in the blood. There are presently no reliable biomarkers with which to predict exacerbations.

Exacerbations have a long-lasting adverse influence on health status. High doses of bronchodilators are the mainstay of treatment and systemic corticosteroids have some benefit. The routine use of antibiotics remains controversial but they are of benefit with exacerbations of a bacterial origin. Noninvasive ventilation is beneficial in preventing the need for intubation and its important complications but it is not certain whether its use in stable patients prevents exacerbations. Although important advances have been made, more effective treatments are needed in the future for prevention and treatment of exacerbations.

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