Case Study

John Hurst
UK
 Exacerbation of COPD:
A Diagnostic Challenge

Dr John Hurst PhD FRCP

Director, UCL-Royal Free COPD Centre
Reader in Respiratory Medicine
UCL Respiratory Medicine, London, UK
j.hurst@ucl.ac.uk
CASE 1, Question 1

•  A 70 year old male with known COPD presents

with worsening breathlessness.
•  The breathlessness started acutely, was
associated with left sided chest pain and has
persisted for three hours. There has been no
change in the amount or volume of his phlegm.
•  Based on the information so far, is this an
exacerbation of COPD?
1.  YES
2.  NO
3.  MAYBE
CASE 1, Question 1
Based on the information so far, is this an exacerbation of
COPD?

1 0%
1.  YES

2 0%
2.  NO

3.  MAYBE 3 0%

1 2 3

0:15 Voted: 0
CASE 1, Question 2

•  A 70 year old male with known COPD presents

with worsening breathlessness.
•  The breathlessness started acutely, was
associated with left sided chest pain and has
persisted for three hours. There has been no
change in the amount or volume of his phlegm.
•  Based on the information so far, is this an
exacerbation of COPD?
1.  YES
2.  NO
3.  MAYBE
CASE 1, Question 2
Based on the information so far, is this an exacerbation of
COPD?

1.  YES 1 0%

2.  NO 2 0%

3 0%
3.  MAYBE
1 2 3

0:15 Voted: 0
CASE 1, Question 3

•  Interpret the chest

radiograph.

•  Is this an exacerbation
of COPD?
1.  YES
2.  NO
3.  MAYBE
CASE 1, Question 3

Is this an exacerbation of COPD?

1.  YES 1 0%

2.  NO 2 0%

3.  MAYBE
3 0%

1 2 3

0:15 Voted: 0
CASE 1, Question 3

•  Interpret the chest

radiograph.

•  Is this an exacerbation
of COPD?
1.  YES
2.  NO: Pneumothorax
3.  MAYBE
KEY POINT 1

A change in symptoms in a patient with COPD is

not necessarily an exacerbation of the COPD itself
CASE 2, Question 1

•  A 70 year old female with known COPD presents with

worsening breathlessness. The breathlessness
deteriorated slowly over a few days, was associated with
right sided chest pain and has persisted. She has a fever.
She is coughing more phlegm than usual, and the phlegm
is a darker colour.

•  Based on the information so far, is this an

exacerbation of COPD?
1.  YES
2.  NO
3.  MAYBE
CASE 2, Question 1

Based on the information so far, is this an exacerbation of

COPD?

1 0%
1.  YES

2.  NO 2 0%

3.  MAYBE 3 0%

1 2 3

0:15 Voted: 0
Chest radiograph

•  Interpret the chest

radiograph.

•  Is this an exacerbation
of COPD?
1.  YES
2.  NO
3.  MAYBE
is this an exacerbation of COPD?

1.  YES 1 0%

2.  NO 2 0%

3.  MAYBE 3 0%

1 2 3

0:15 Voted: 0
Chest radiograph
•  Interpret the chest
radiograph.

•  Is this an exacerbation
of COPD?
1.  YES
2.  NO: Pneumonia
3.  MAYBE

•  Does this distinction

matter?
CASE 2, Question 2

Is there a distinction to be made between

pneumonia and exacerbation of COPD
1.  YES
2.  NO
3.  UNSURE
CASE 2, Question 2
Is there a distinction to be made between pneumonia and
exacerbation of COPD?

1.  YES 1 0%

2.  NO 2 0%

3.  UNSURE 3 0%

1 2 3

0:15 Voted: 0
KEY POINT 2

There is a clinical distinction between

exacerbation of COPD and pneumonia
Treatment
COPD Exacerbation COPD with Pneumonia

Increased bronchodilators ?
Antibiotics: amoxicillin Antibiotics: co-amoxiclav + macrolide
Oral Corticosteroids NO STEROID
Prognosis

Receiver operator characteristic curve showing discrimination of Dyspnoea, Eosinopenia,

Consolidation, Acidaemia and atrial Fibrillation (DECAF) Score and CURB-65 for in hospital
mortality for patients with (n=299, panel A) and without (n=621, panel B) consolidation.

Steer J et al. Thorax 2012;67:970-976

Discussion

John Hurst
University College London
London, UK
j.hurst@ucl.ac.uk