ORIGINAL ARTICLE

Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease

G C Donaldson, T A R Seemungal, A Bhowmik, J A Wedzicha

Academic Unit of Respiratory Medicine, St Bartholomew’s and Royal London School of Medicine and Dentistry, London EC1A 7BE, UK

Correspondence to:
Correspondence to:
Professor J A Wedzicha, Academic Unit of Respiratory Medicine, Dominion House, St Bartholomew’s Hospital, London EC1A 7BE, UK;
j.a.wedzicha{at}qmul.ac.uk

Background: Chronic obstructive pulmonary disease (COPD) is characterised by both an accelerated decline in lung function and periods of acute deterioration in symptoms termed exacerbations. The aim of this study was to investigate whether these are related.

Methods: Over 4 years, peak expiratory flow (PEF) and symptoms were measured at home daily by 109 patients with COPD (81 men; median (IQR) age 68.1 (63–74) years; arterial oxygen tension (PaO₂) 9.00 (8.3–9.5) kPa, forced expiratory volume in 1 second (FEV₁) 1.00 (0.7–1.3) l, forced vital capacity (FVC) 2.51 (1.9–3.0) l); of these, 32 (29 men) recorded daily FEV₁. Exacerbations were identified from symptoms and the effect of frequent or infrequent exacerbations (> or < 2.92 per year) on lung function decline was examined using cross sectional, random effects models.

Results: The 109 patients experienced 757 exacerbations. Patients with frequent exacerbations had a significantly faster decline in FEV₁ and peak expiratory flow (PEF) of –40.1 ml/year (n=16) and –2.9 l/min/year (n=46) than infrequent exacerbators in whom FEV₁ changed by –32.1 ml/year (n=16) and PEF by –0.7 l/min/year (n=63). Frequent exacerbators also had a greater decline in FEV₁ if allowance was made for smoking status. Patients with frequent exacerbations were more often admitted to hospital with longer length of stay. Frequent exacerbations were a consistent feature within a patient, with their number positively correlated (between years 1 and 2, 2 and 3, 3 and 4).

Conclusions: These results suggest that the frequency of exacerbations contributes to long term decline in lung function of patients with moderate to severe COPD.

Keywords: chronic obstructive pulmonary disease; exacerbations; lung function

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• Anzueto, A., Sethi, S., Martinez, F. J. (2007). Exacerbations of Chronic Obstructive Pulmonary Disease. Proc Am Thorac Soc 4: 554-564 [Abstract] [Full Text]  
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• Bai, T. R., Vonk, J. M., Postma, D. S., Boezen, H. M. (2007). Severe exacerbations predict excess lung function decline in asthma. Eur Respir J 30: 452-456 [Abstract] [Full Text]  
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• Ko, F. W S, Tam, W., Wong, T. W., Chan, D. P S, Tung, A. H, Lai, C. K W, Hui, D. S C (2007). Temporal relationship between air pollutants and hospital admissions for chronic obstructive pulmonary disease in Hong Kong. Thorax 62: 780-785 [Abstract] [Full Text]  
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• Beaulieu-Genest, L., Chretien, D., Maltais, F., Pelletier, K., Parent, J.-G., Lacasse, Y. (2007). Self-administered prescriptions of oral steroids and antibiotics in chronic obstructive pulmonary disease: are we doing more harm than good?. Chronic Respiratory Disease 4: 143-147 [Abstract]  
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• James, A. L., Wenzel, S. (2007). Clinical relevance of airway remodelling in airway diseases. Eur Respir J 30: 134-155 [Abstract] [Full Text]  
• Celli, B. R., Barnes, P. J. (2007). Exacerbations of chronic obstructive pulmonary disease. Eur Respir J 29: 1224-1238 [Abstract] [Full Text]  
• Siva, R., Green, R. H., Brightling, C. E., Shelley, M., Hargadon, B., McKenna, S., Monteiro, W., Berry, M., Parker, D., Wardlaw, A. J., Pavord, I. D. (2007). Eosinophilic airway inflammation and exacerbations of COPD: a randomised controlled trial. Eur Respir J 29: 906-913 [Abstract] [Full Text]  
• Gunen, H., Hacievliyagil, S. S., Yetkin, O., Gulbas, G., Mutlu, L. C., In, E. (2007). The role of nebulised budesonide in the treatment of exacerbations of COPD. Eur Respir J 29: 660-667 [Abstract] [Full Text]  
• Cote, C. G., Dordelly, L. J., Celli, B. R. (2007). Impact of COPD Exacerbations on Patient-Centered Outcomes. Chest 131: 696-704 [Abstract] [Full Text]  
• Wang, Y.-C., Lin, J.-M., Li, C.-Y., Lee, L.-T., Guo, Y.-L., Sung, F.-C. (2007). Prevalence and Risks of Chronic Airway Obstruction: A Population Cohort Study in Taiwan. Chest 131: 705-710 [Abstract] [Full Text]  
• Perera, W. R., Hurst, J. R., Wilkinson, T. M. A., Sapsford, R. J., Mullerova, H., Donaldson, G. C., Wedzicha, J. A. (2007). Inflammatory changes, recovery and recurrence at COPD exacerbation. Eur Respir J 29: 527-534 [Abstract] [Full Text]  
• Kardos, P., Wencker, M., Glaab, T., Vogelmeier, C. (2007). Impact of Salmeterol/Fluticasone Propionate versus Salmeterol on Exacerbations in Severe Chronic Obstructive Pulmonary Disease. Am. J. Respir. Crit. Care Med. 175: 144-149 [Abstract] [Full Text]  
• Ko, F. W.S., Ip, M., Chan, P. K.S., Fok, J. P.C., Chan, M. C.H., Ngai, J. C., Chan, D. P.S., Hui, D. S.C. (2007). A 1-Year Prospective Study of the Infectious Etiology in Patients Hospitalized With Acute Exacerbations of COPD. Chest 131: 44-52 [Abstract] [Full Text]  
• Koch, A., Gaczkowski, M., Sturton, G., Staib, P., Schinkothe, T., Klein, E., Rubbert, A., Bacon, K., Wassermann, K., Erdmann, E. (2007). Modification of surface antigens in blood CD8+ T-lymphocytes in COPD: effects of smoking. Eur Respir J 29: 42-50 [Abstract] [Full Text]  
• Brusasco, V. (2006). Reducing cholinergic constriction: the major reversible mechanism in COPD. ERR 15: 32-36 [Abstract] [Full Text]  
• Rodriguez-Roisin, R. (2006). Impacting patient-centred outcomes in COPD: exacerbations and hospitalisations. ERR 15: 47-51 [Abstract] [Full Text]  
• Knox, A, Britton, J (2006). Thorax 1996-2002. Thorax 61: 1020-1021 [Full Text]  
• Hurst, J. R., Donaldson, G. C., Perera, W. R., Wilkinson, T. M. A., Bilello, J. A., Hagan, G. W., Vessey, R. S., Wedzicha, J. A. (2006). Use of Plasma Biomarkers at Exacerbation of Chronic Obstructive Pulmonary Disease. Am. J. Respir. Crit. Care Med. 174: 867-874 [Abstract] [Full Text]  
• Innes, A. L., Woodruff, P. G., Ferrando, R. E., Donnelly, S., Dolganov, G. M., Lazarus, S. C., Fahy, J. V. (2006). Epithelial mucin stores are increased in the large airways of smokers with airflow obstruction.. Chest 130: 1102-1108 [Abstract] [Full Text]  
• Mallia, P., Johnston, S. L. (2006). How viral infections cause exacerbation of airway diseases.. Chest 130: 1203-1210 [Abstract] [Full Text]  
• Ramsey, S. D., Hobbs, F. D. R. (2006). Chronic Obstructive Pulmonary Disease, Risk Factors, and Outcome Trials: Comparisons with Cardiovascular Disease. Proc Am Thorac Soc 3: 635-640 [Abstract] [Full Text]  
• Kessler, R., Stahl, E., Vogelmeier, C., Haughney, J., Trudeau, E., Lofdahl, C.-G., Partridge, M. R. (2006). Patient Understanding, Detection, and Experience of COPD Exacerbations: An Observational, Interview-Based Study.. Chest 130: 133-142 [Abstract] [Full Text]  
• Casas, A., Troosters, T., Garcia-Aymerich, J., Roca, J., Hernandez, C., Alonso, A., del Pozo, F., de Toledo, P., Anto, J. M., Rodriguez-Roisin, R., Decramer, M., members of the CHRONIC Project, (2006). Integrated care prevents hospitalisations for exacerbations in COPD patients. Eur Respir J 28: 123-130 [Abstract] [Full Text]  
• Nici, L., Donner, C., Wouters, E., Zuwallack, R., Ambrosino, N., Bourbeau, J., Carone, M., Celli, B., Engelen, M., Fahy, B., Garvey, C., Goldstein, R., Gosselink, R., Lareau, S., MacIntyre, N., Maltais, F., Morgan, M., O'Donnell, D., Prefault, C., Reardon, J., Rochester, C., Schols, A., Singh, S., Troosters, T., on behalf of the ATS/ERS Pulmonary Rehabilitation, (2006). American thoracic society/european respiratory society statement on pulmonary rehabilitation.. Am. J. Respir. Crit. Care Med. 173: 1390-1413 [Full Text]  
• Papi, A., Bellettato, C. M., Braccioni, F., Romagnoli, M., Casolari, P., Caramori, G., Fabbri, L. M., Johnston, S. L. (2006). Infections and Airway Inflammation in Chronic Obstructive Pulmonary Disease Severe Exacerbations. Am. J. Respir. Crit. Care Med. 173: 1114-1121 [Abstract] [Full Text]  
• Wedzicha, J. A., Wilkinson, T. (2006). Impact of Chronic Obstructive Pulmonary Disease Exacerbations on Patients and Payers. Proc Am Thorac Soc 3: 218-221 [Abstract] [Full Text]  
• Papi, A., Luppi, F., Franco, F., Fabbri, L. M. (2006). Pathophysiology of Exacerbations of Chronic Obstructive Pulmonary Disease. Proc Am Thorac Soc 3: 245-251 [Abstract] [Full Text]  
• Scott, S, Walker, P, Calverley, P M A (2006). COPD exacerbations {middle dot} 4: Prevention. Thorax 61: 440-447 [Abstract] [Full Text]  
• O'Donnell, R, Breen, D, Wilson, S, Djukanovic, R (2006). Inflammatory cells in the airways in COPD. Thorax 61: 448-454 [Abstract] [Full Text]  
• Wilkinson, T. M. A., Donaldson, G. C., Johnston, S. L., Openshaw, P. J. M., Wedzicha, J. A. (2006). Respiratory Syncytial Virus, Airway Inflammation, and FEV1 Decline in Patients with Chronic Obstructive Pulmonary Disease. Am. J. Respir. Crit. Care Med. 173: 871-876 [Abstract] [Full Text]  
• Zielinski, J., Bednarek, M., Gorecka, D., Viegi, G., Hurd, S. S., Fukuchi, Y., Lai, C. K. W., Ran, P. X., Ko, F. W. S., Liu, S. M., Zheng, J. P., Zhong, N. S., Ip, M. S. M., Vermeire, P. A. (2006). Increasing COPD awareness.. Eur Respir J 27: 833-852 [Full Text]  
• Wilson, R, Jones, P, Schaberg, T, Arvis, P, Duprat-Lomon, I, Sagnier, P P, for the MOSAIC Study Group, (2006). Antibiotic treatment and factors influencing short and long term outcomes of acute exacerbations of chronic bronchitis. Thorax 61: 337-342 [Abstract] [Full Text]  
• Pitta, F., Troosters, T., Probst, V. S., Spruit, M. A., Decramer, M., Gosselink, R. (2006). Physical Activity and Hospitalization for Exacerbation of COPD. Chest 129: 536-544 [Abstract] [Full Text]  
• Donaldson, G C, Wedzicha, J A (2006). COPD exacerbations {middle dot} 1: Epidemiology. Thorax 61: 164-168 [Abstract] [Full Text]  
• Celli, B. R. (2006). Chronic Obstructive Pulmonary Disease: From Unjustified Nihilism to Evidence-based Optimism.. Proc Am Thorac Soc 3: 58-65 [Abstract] [Full Text]  
• Hurst, J. R., Perera, W. R., Wilkinson, T. M. A., Donaldson, G. C., Wedzicha, J. A. (2006). Systemic and Upper and Lower Airway Inflammation at Exacerbation of Chronic Obstructive Pulmonary Disease. Am. J. Respir. Crit. Care Med. 173: 71-78 [Abstract] [Full Text]  
• Vestbo, J, Hogg, J C (2006). Convergence of the epidemiology and pathology of COPD. Thorax 61: 86-88 [Abstract] [Full Text]  
• Braman, S. S. (2006). Chronic Cough Due to Chronic Bronchitis: ACCP Evidence-Based Clinical Practice Guidelines. Chest 129: 104S-115S [Abstract] [Full Text]  
• Stevenson, N. J., Walker, P. P., Costello, R. W., Calverley, P. M. A. (2005). Lung Mechanics and Dyspnea during Exacerbations of Chronic Obstructive Pulmonary Disease. Am. J. Respir. Crit. Care Med. 172: 1510-1516 [Abstract] [Full Text]  
• Bhowmik, A., Seemungal, T. A. R., Donaldson, G. C., Wedzicha, J. A. (2005). Effects of exacerbations and seasonality on exhaled nitric oxide in COPD. Eur Respir J 26: 1009-1015 [Abstract] [Full Text]  
• Soler, M. (2005). Modulation of airway inflammation to prevent exacerbations of COPD. ERR 14: 78-82 [Abstract] [Full Text]  
• Wedzicha, J A, Seemungal, T A R (2005). Inhaled corticosteroids in COPD: a light at the end of the tunnel?. Thorax 60: 977-978 [Full Text]  
• Hurst, J. R., Donaldson, G. C., Wilkinson, T. M. A., Perera, W. R., Wedzicha, J. A. (2005). Epidemiological relationships between the common cold and exacerbation frequency in COPD. Eur Respir J 26: 846-852 [Abstract] [Full Text]  
• Mallia, P., Johnston, S. L. (2005). Mechanisms and Experimental Models of Chronic Obstructive Pulmonary Disease Exacerbations. Proc Am Thorac Soc 2: 361-366 [Abstract] [Full Text]  
• Soler-Cataluna, J J, Martinez-Garcia, M A, Roman Sanchez, P, Salcedo, E, Navarro, M, Ochando, R (2005). Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax 60: 925-931 [Abstract] [Full Text]  
• Haughney, J., Partridge, M. R., Vogelmeier, C., Larsson, T., Kessler, R., Stahl, E., Brice, R., Lofdahl, C-G. (2005). Exacerbations of COPD: quantifying the patient's perspective using discrete choice modelling. Eur Respir J 26: 623-629 [Abstract] [Full Text]  
• Donaldson, G. C., Seemungal, T. A. R., Patel, I. S., Bhowmik, A., Wilkinson, T. M. A., Hurst, J. R., MacCallum, P. K., Wedzicha, J. A. (2005). Airway and Systemic Inflammation and Decline in Lung Function in Patients With COPD. Chest 128: 1995-2004 [Abstract] [Full Text]  
• Calverley, P., Pauwels{dagger}, R., Lofdahl, C-G., Svensson, K., Higenbottam, T., Carlsson, L-G., Stahl, E. (2005). Relationship between respiratory symptoms and medical treatment in exacerbations of COPD. Eur Respir J 26: 406-413 [Abstract] [Full Text]  
• Vincken, W. (2005). Bronchodilator treatment of stable COPD: long-acting anticholinergics. ERR 14: 23-31 [Abstract] [Full Text]  
• Wilson, R. (2005). Treatment of COPD exacerbations: antibiotics. ERR 14: 32-38 [Abstract] [Full Text]