Exacerbations of COPD are a major cause of morbidity and mortality in patients with COPD It is estimated that there are 16 million office visits.

Exacerbations of COPD are a major cause of morbidity and mortality in patients with COPD It is estimated that there are 16 million office visits, 500000 hospitalizations, and 110000 deaths attributed to COPD in the United States each year. (12) A great majority of the office visits are owed to COPD exacerbations that are treated in the outpatient setting. Patients who are admitted to the ICU for COPD exacerbations have an in-hospital mortality of 24% (3)

A diagnosis of COPD exacerbation is considered when there is increased dyspnea, increased sputum dimensions and increased sputum purulence. Severity of an exacerbation can be quantified by means of assessing the magnitude of these three symptoms, as described by means of Anthonisen et al. (4) In a prototype 1 exacerbation, all three symptoms are present; in a token 2 exacerbation, any two of the three symptoms are present; and a pattern 3 exacerbation has only the same symptom with any one of the following features: upper respiratory tract infection in the past 5 days, agitation without cause, increased wheezing, cough tachypnea, or heart rate of 20% above baseline. A chest radiograph is not done routinely in the outpatient setting unles pneumonia is suspected or if the patient is being considered for hospital admission based onward the severity of initial symptoms. In pair retrospective studies, chest radiograph abnormalities were reported in 16% of patients who were admitted to the hospital for COPD exacerbation. (56)

Airway infections of the tracheobronchial tree are responsible for the majority of exacerbations in COPD Acute exacerbations are also associated with increased bronchial inflammation, as evidenced by dint of influx of sputum neutrophils with elevated evens of myeloperoxidase and elastases along with increased flats of sputum cytokines such as interleukin (IL)-6, IL-8, tumor necrosis factor-[alpha], and leukotriene [Bsub4] (78) Approximately 50% of the exacerbations are caused on bacterial pathogens, 30% by viral infections, and the remaining exacerbations are caused by dint of atypical pathogens and environmental allergen outlooks Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis are the three chiefly common bacterial pathogens, while Gram-negative bacilli like Pseudomonas aeruginosa may be involved in a subset of patients with more rigorous lung disease. (9) Atypical pathogens like Mycoplasma pneumoniae and Chlamydia pneumoniae may be responsible for < 10% of the exacerbations. (10)

The major goals for treatment of acute exacerbation of COPD are quick improvement of symptoms with reduction in relapse rates and hospitalization. Treatment options for acute exacerbation of COPD include increased frequent occurrence of inhaled bronchodilators, use of oral steroids for 2 weeks in exquisite patients, and antibiotics. Although the part of antibiotics has been questioned by the agency of some, results of 11 randomized controll trials demonstrate a beneficial efficiency with the use of antibiotics in patients with moderate-to-severe COPD exacerbations. (11) The chiefly commonly used antibiotics, also referr to as first-line antibiotics, include amoxicillin, trimethoprim-sulfamethoxazole, erythromycin, and doxycycline; while the newer antibiotics, referr to as second-line, broad-spectrum antibiotics, include the newer second-generation and third-generation cephalosporins, fluoroquinolones, lengthen outed spectrum macrolides, and [beta]-lactamase-inhibitor combination.

Factors that are associated with poor treatment result include severity of underlying illnesses as judg by means of the type of exacerbation (type 1 v prototype 3), type of pathogens with their susceptibility, and resistance patterns. entertainer factors include severity of airflow obstruction (FE[Vsub1] < 35% of predicted), ne for abiding-place oxygen, use of chronic steroid therapy, commonness of exacerbations (four or more through year), and presence of comorbid medical conditions in the same state [i]or[/i] condition as congestive heart failure. The choice of antibiotics is generally guided by means of the severity of exacerbation, carriage of risk factors, and the token of pathogens expected. (12,13) Several studies in the pre-1990 era did not exhibit to a difference in the treatment result based on the choice of antibiotics. (11) However, there is great business over recent reports of increasing resistance to the principally commonly used first-line antibiotics among the bacterial pathogens as it is as H influenzae and s pneumoniae. (14,15) In one retrospective investigation the use of newer antibiotics reduc the failure and hospitalization rate when compared to first-line antibiotics. (16) In a other study, treatment with amoxicillin was associated with a higher failure rate when compared to other antibiotics. (17) In a prospective thought the use of ciprofloxacin as compared to the usual antibiotics, in patients with moderate-to-severe chronic bronchitis who had four or more exacerbations, was associated with improved issue (18) In general, the comes of multiple studies demonstrate that patients who have lower FE[Vsub1] values, who require more intensive therapy with bronchodilators and steroids, and patients who have not accorded to treatment on prior episodes of acute exacerbations are more likely to relapse within the nearest 14 to 30 days, as compared to patients with more favorable parameters. (11)

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