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Building toolkits for COPD exacerbations: lessons from the past and present
  1. Elizabeth Sapey1,
  2. Mona Bafadhel2,
  3. Charlotte E Bolton3,
  4. Thomas Wilkinson4,
  5. John R Hurst5,
  6. Jennifer K Quint6
  1. 1 Birmingham Acute Care Research, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
  2. 2 Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
  3. 3 Respiratory Medicine, NIHR Nottingham BRC, University of Nottingham, Nottingham, UK
  4. 4 Clinical and Experimental Medicine, University of Southampton, Southampton, UK
  5. 5 Academic Unit of Respiratory Medicine, UCL Medical School, London, UK
  6. 6 Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College London, London, UK
  1. Correspondence to Elizabeth Sapey, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK; e.sapey{at}


In the nineteenth century, it was recognised that acute attacks of chronic bronchitis were harmful. 140 years later, it is clearer than ever that exacerbations of chronic obstructive pulmonary disease (ECOPD) are important events. They are associated with significant mortality, morbidity, a reduced quality of life and an increasing reliance on social care. ECOPD are common and are increasing in prevalence. Exacerbations beget exacerbations, with up to a quarter of in-patient episodes ending with readmission to hospital within 30 days. The healthcare costs are immense. Yet despite this, the tools available to diagnose and treat ECOPD are essentially unchanged, with the last new intervention (non-invasive ventilation) introduced over 25 years ago.

An ECOPD is ‘an acute worsening of respiratory symptoms that results in additional therapy’. This symptom and healthcare utility-based definition does not describe pathology and is unable to differentiate from other causes of an acute deterioration in breathlessness with or without a cough and sputum. There is limited understanding of the host immune response during an acute event and no reliable and readily available means to identify aetiology or direct treatment at the point of care (POC). Corticosteroids, short acting bronchodilators with or without antibiotics have been the mainstay of treatment for over 30 years. This is in stark contrast to many other acute presentations of chronic illness, where specific biomarkers and mechanistic understanding has revolutionised care pathways. So why has progress been so slow in ECOPD? This review examines the history of diagnosing and treating ECOPD. It suggests that to move forward, there needs to be an acceptance that not all exacerbations are alike (just as not all COPD is alike) and that clinical presentation alone cannot identify aetiology or stratify treatment.

  • copd exacerbations
  • innate immunity
  • emphysema

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Correction notice This article has been corrected since it was published. Charlotte Emma Bolton's name was adjusted to Charlotte E Bolton and her affiliation changed from "Nottingham Respiratory BRU" to "NIHR Nottingham BRC".

  • Contributors All authors wrote the manuscript and all contributed to the manuscript equally.

  • Funding E Sapey was funded by the Medical Research Council, grant number MR/R003157/1. Other authors received no specific grant for this work from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests No, there are no competing interests for any author.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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