<h1>Chronic Obstructive Pulmonary Disease (COPD) is a major health concern globally, with a significant impact on the quality of life and life expectancy of affected individuals. Surya Bhatt, a distinguished professor of medicine at the University of Alabama at Birmingham and a COPD researcher, provides valuable insights into the progression and management of this disease. This article will delve into key aspects of COPD exacerbations, drawing on the expertise of Dr. Bhatt to enhance our understanding.</h1>

CHRONIC-OBSTRUCTIVE-PULMONARY-DISEASE-(COPD)

The burden and Risk of Exacerbations in COPD according to Dr. Surya Bhatt

Read podcast transcript

<h2>What is COPD?</h2>
COPD is a chronic inflammatory lung disease that causes obstructed airflow from the lungs.1 Symptoms include breathing difficulty, cough, mucus (sputum) production, and wheezing. It is typically caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke. Individuals with COPD are at increased risk of developing heart disease, lung cancer, and a variety of other conditions.1

<h2>The Critical Role of Exacerbations in COPD Progression</h2>
Dr. Bhatt emphasizes that acute exacerbations of COPD are not merely inconveniences but are pivotal events that significantly influence the course of the disease. "One of the other things that's very important in COPD is acute exacerbations. And these are not just an inconvenience but are associated with significant disease progression," he states. Exacerbations are typically triggered by infections such as viruses and bacterial infections or by environmental pollution and occupational exposures.1
<h3>Impact on Lung Function</h3>
Exacerbations have a profound impact on lung function, with data suggesting a link between exacerbations and accelerated lung function decline.1 Dr. Bhatt notes, "There's plenty of data to suggest that these exacerbations are associated with lung function decline." This decline is more severe in the case of frequent exacerbations. For instance, he cites the COPD Gene study, which shows how the frequency of exacerbations correlates with the rate of FEV1 decline—a measure of lung function.2

<h3>Severity and Treatment1</h3>
The severity of exacerbations can vary, significantly affecting treatment approaches and outcomes.1 "But if they manage to adjust steroids and antibiotics at home, that classifies as a moderate exacerbation. But if it's severe enough to end up in the hospital, then that causes a severe exacerbation," explains Dr. Bhatt. The distinction between moderate and severe exacerbations is crucial as it determines the immediate treatment protocol and the long-term management strategy.

<h2>The Cascading Effects of Severe Exacerbations</h2>
Severe exacerbations are particularly concerning due to their cascading effects on health. Dr. Bhatt discusses a study by Samy Suissa, which modeled severe exacerbation frequency among approximately 75,000 patients in Canada.3 The study found that the interval between exacerbations tends to decrease over time, indicating a worsening pattern of the disease. "When somebody gets a first exacerbation, it seems like it begets more exacerbations," he explains.
<h3>Mortality Risks</h3>
The mortality risks associated with severe exacerbations are stark. Dr. Bhatt highlights, "The hazards of mortality is about twice if you get two severe exacerbations as opposed to one severe exacerbation. And the hazards of mortality is fivefold if you get ten exacerbations as opposed to one severe exacerbation." Furthermore, the risk of dying within one year of a severe exacerbation requiring hospitalization is about 25%, which increases to 50% within four years after discharge.

<h2>In Summary</h2>
The insights provided by Dr. Surya Bhatt illuminate the severe implications of COPD exacerbations. Understanding the triggers, frequency, and severity of these exacerbations is crucial for managing COPD effectively. As research continues to evolve, it is essential for healthcare providers to stay informed about the best practices for treating and managing exacerbations to improve the quality of life for COPD patients. Additionally, preventative strategies, including smoking cessation and reducing exposure to pollutants, remain key components of COPD management. Through a comprehensive approach that includes both prevention and effective exacerbation management, the impact of COPD can be significantly mitigated.

Chronic Obstructive Pulmonary Disease (COPD) is a major health concern globally, with a significant impact on the quality of life and life expectancy of affected individuals. Surya Bhatt, a distinguished professor of medicine at the University of Alabama at Birmingham and a COPD researcher, provides valuable insights into the progression and management of this disease. This article will delve into key aspects of COPD exacerbations, drawing on the expertise of Dr. Bhatt to enhance our understanding.

Eosinophils in COPD&nbsp;
In patients with COPD, raised eosinophil levels in the blood are associated with higher eosinophil levels in the lungs, which is a biomarker of type 2 inflammatory activity in the airway.1-4&nbsp;It has been found that up to 37% of COPD patients show indication of type 2 inflammation.5&nbsp;
<ul>
 <li><a href="https://pro.campus.sanofi/copd/articles/role-of-type-2-inflammation">Link to Role of Type 2 Inflammation in COPD</a>&nbsp;</li>
</ul>
Raised blood eosinophil levels are detectable by ordering a complete blood count with differential. A large population-based study (N=39,824) evaluated the stability of blood eosinophilia over time. The stability of the blood eosinophil count was observed to be higher in patients with COPD with baseline counts &lt;340 cells/µL vs ≥340 cells/µL. The findings from this study extend the understanding of blood eosinophil as a potential biomarker.5 &nbsp;
Raised blood eosinophil count in COPD is associated with poor clinical outcomes and increased healthcare cost&nbsp;
Raised blood eosinophil count in COPD increased the risk of exacerbation,6 1-year COPD-related readmission,7 and severe exacerbations8 as shown in the illustration below:&nbsp;

COPD exacerbation risk increases with higher eosinophil counts. In the COPDGene study, COPD patients with blood eosinophil count ≥300 cells/μL demonstrated an increased risk of exacerbations. This was prospectively validated in the ECLIPSE study.6
&nbsp;
Type 2 inflammation in COPD (Eosinophilic COPD) and its risks&nbsp;
Raised blood eosinophils are associated with higher emergency department visits, outpatient visits, numbers of prescriptions* and increased rate of lung function decline.9,10 Raised eosinophils in COPD may also lead to increased risk of 1-year COPD-related readmission, decreased time to first COPD-related readmission and increased number of 1-year COPD-related Emergency Department (ED) visits7 as shown in the illustration and table below: &nbsp;
Risks associated with raised blood eosinophil levels&nbsp;

To learn more about the impact of raised eosinophiles in COPD read this article&nbsp;
An Overview of the impact of Type 2 Inflammation in COPD: Insights from Dr. Surya Bhatt&nbsp;
&nbsp;
<h2>Impact of blood eosinophil count in COPD on management decisions&nbsp;</h2>

Initial pharmacological management (Group E†)1:&nbsp;
GOLD references suggest that ICS should be added to long-acting bronchodilators therapy in patients with high blood eosinophils counts (≥300 cells/µL). Consider triple therapy (LABA+LAMA+ICS) if eosinophil count is ≥300 cells/μL and this is based on the effect of ICS on exacerbation prevention correlated to blood eosinophil count. There is no direct data on initiation with triple therapy in newly diagnosed patients. However, available studies in treated patients provide a rationale to initiate treatment with triple therapy in patients with high eosinophils counts (≥300 cells/µL).1&nbsp;
&nbsp;
Blood eosinophil count impact on initial management decisions, according to GOLD references1&nbsp;

Follow-up pharmacological management:&nbsp;
Exacerbations:1 &nbsp;
GOLD references recommend escalation to LABA + LAMA for patients with persistent exacerbations on bronchodilator therapy.&nbsp;
ICS is suggested to be added to LABA + LAMA in patients who develop further exacerbations. Beneficial response of ICS may be observed at blood eosinophil counts of ≥100 cells/μL.&nbsp;
For patients treated with LABA + LAMA + ICS or those with eosinophil counts of &lt;100 cells/μL who still have exacerbations — <a href="https://goldcopd.org/2025-gold-report/">Please refer to GOLD guidelines for more information</a>&nbsp;
&nbsp;
Blood eosinophil count impact on follow-up pharmalogical management decisions, according to GOLD1&nbsp;

*Regardless of inhaled therapy&nbsp;
†Group “E” are patients with frequent exacerbations (defined as ≥2 in the past 12 months or 1 exacerbation requiring hospitalization).&nbsp;
&nbsp;
COPD, chronic obstructive pulmonary disease; ED, emergency department; FEV1, forced expiratory volume in first second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; HR, hazard ratio; ICS, inhaled corticosteroid; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; OR, odds ratio; IRR, incidence rate ratio; ULN, upper limit of normal.&nbsp;

This article discusses the role of blood eosinophils as a biomarker in patients with Chronic Obstructive Pulmonary Disease (COPD). It highlights that measuring blood eosinophil levels can help predict exacerbations, guide corticosteroid therapy, and tailor treatment strategies for COPD patients. The article emphasizes the importance of personalized treatment approaches based on eosinophil counts to improve patient outcomes and manage COPD more effectively.

Blood Eosinophils as a Biomarker in Patients with COPD

COPD exacerbation is an event characterized by increased dyspnea and/or cough and sputum that worsens in less than 14 days and may be accompanied with tachypnea and/or tachycardia.2&nbsp;
COPD exacerbations are often associated with increased local and systemic inflammation caused by airway infection, air pollutants, or other airway insults.2 Type 2 inflammation, characterized by raised eosinophil count, is associated with increased risk of COPD exacerbations.3 &nbsp;
Click <a href="https://pro.campus.sanofi/copd/articles/an-overview-of-the-impact-of-type-2-inflammation-in-copd-insights-from-dr-surya-bhatt">here</a> to understand how type 2 inflammation is linked to the risk of COPD exacerbations.
The treatment goals of COPD exacerbations are to minimize the negative impact of the current exacerbation and to prevent occurrence of subsequent events.2 The risk of subsequent events has been shown to increase with each exacerbation.1&nbsp;Furthermore, frequent COPD exacerbations lead to accelerated lung function decline4 and worsening of symptoms.2
To know more, listen to the <a href="https://www.emjreviews.com/respiratory/podcasts/the-negative-impact-of-chronic-inflammation-on-quality-of-life-in-patients-with-copd/">podcast</a> on COPD exacerbations and their impact on patients’ quality of life by Prof. Nicola Hanania, Professor of Medicine, Section Chief of Pulmonary Critical Care and Sleep Medicine at the Ben Taub Hospital in Houston, Texas, and Director of the Airways Clinical Research Center, ACRC at the Bear College of Medicine.
&nbsp;
<h2>Pathophysiology of acute COPD exacerbation&nbsp;</h2>
COPD exacerbations are often associated with increased local and systemic inflammation.2 Air pollutants, such as particulate matter, sulfur dioxide, and cigarette smoke can increase exacerbations. 5,6 &nbsp;
In stable COPD, there is an increase in the release of inflammatory cells such as T- lymphocytes and macrophages in the bronchial mucosa.6 In patients with stable, but more severe COPD, there is an increase in airway neutrophils, which further elevate during exacerbations.6&nbsp;
A substantial percentage of patients with COPD show raised eosinophils in the airways, lungs, and blood;2 however, significant variations in blood eosinophil levels are observed during both stable COPD and acute exacerbations.7 Eosinophilic inflammation has been attributed as a cause for exacerbations. Patients with raised eosinophils during stable disease experience frequent and severe exacerbations.7 Patients with mild COPD and exacerbations have also demonstrated an increased number of eosinophils in their airways on bronchial biopsy.6&nbsp;
To know more, please read the article <a href="https://pro.campus.sanofi/copd/articles/blood-eosinophils-as-a-biomarker-in-patients-with-copd">Blood Eosinophils as a Biomarker in Patients with COPD</a>.
According to Dr Surya Bhatt, a distinguished professor of medicine at the University of Alabama at Birmingham and a COPD researcher, the burden and risk of exacerbations in COPD is profound and "there's plenty of data to suggest that these exacerbations are associated with lung function decline."
Click <a href="https://pro.campus.sanofi/copd/articles/the-burden-and-risk-of-exacerbations-in-copd-according-to-dr-surya-bhatt">here</a> to watch the full video by Dr Surya Bhatt.

<h2>Etiology of acute COPD exacerbation</h2>
COPD exacerbations are triggered by a variety of factors including airway infection, air pollution or other airway insults, with viral infections being a key trigger.2&nbsp;
Viral infections result in more severe exacerbations that are associated with longer recovery times, compared with those triggered by other factors.2 Such exacerbations also have a greater likelihood of hospital admission. Human rhinovirus, influenza and parainfluenza and metapneumovirus are the most common viruses implicated in airway infections causing exacerbations and can be isolated within a week of onset of exacerbation.2&nbsp;
The exact role of bacteria as a causative agent in COPD exacerbations remains uncertain as the same bacteria were identified in both stable disease and during exacerbations.6 Short-term exposure to environmental pollutants, such as particulate matter and nitrous oxide, has been linked to increased exacerbations, hospital admissions, emergency room, and outpatient visits and increased mortality.2&nbsp;
Read more about the impact of exacerbations in COPD <a href="https://pro.campus.sanofi/copd/articles/the-impact-of-exacerbations-in-copd">here</a>.

Dr. Surya Bhatt <a href="https://pro.campus.sanofi/copd/articles/the-burden-and-risk-of-exacerbations-in-copd-according-to-dr-surya-bhatt">highlights</a>, "The hazard of mortality is about twice if you get two severe exacerbations as opposed to one severe exacerbation. And the hazard of mortality is fivefold if you get ten exacerbations as opposed to one severe exacerbation."
Click <a href="https://pro.campus.sanofi/copd/articles/the-burden-and-risk-of-exacerbations-in-copd-according-to-dr-surya-bhatt">here</a> to watch Dr. Surya Bhatt’s video where he talks about the burden and risk of exacerbations in COPD.&nbsp;
&nbsp;
<h2>Symptoms of acute COPD exacerbation</h2>
COPD exacerbations may be associated with a wide range of clinical signs and symptoms.5 The signs and symptoms during exacerbation are similar to what the patients usually experience; however, their severity is increased. COPD exacerbations are associated with deterioration in airflow limitation and dynamic hyperinflation, occurring as a result of bronchospasm, airway edema and excessive sputum production due to airway inflammatory responses.6 These changes primarily contribute to increased dyspnea, the most common symptom experienced during exacerbations.6
The other symptoms of COPD exacerbation include severe and strenuous cough, increased sputum volume, change in sputum color from whitish to yellow/green, and hemoptysis.5 On physical examination, increase in expiratory wheezing and rhonchi may be evident along with warning signs of impending respiratory failure, such as paradoxical breathing and respiratory alternans due to muscle fatigue.5
&nbsp;
<h2>COPD exacerbation criteria and diagnosis&nbsp;</h2>
Several staging systems for classification of the severity of COPD exacerbations without respiratory failure were used previously; however, none were prospectively validated.5 The 2025 GOLD report proposed a classification system for exacerbation severity, using the Delphi approach after an exhaustive literature review.2&nbsp;
Exacerbations can be classified as mild, moderate, and severe after their onset.2 Classification of COPD exacerbation severity should be followed up with identification of cause by viral testing, sputum culture or other investigations.&nbsp;
&nbsp;
Classification of COPD exacerbation severity2,8

Click <a href="https://goldcopd.org/2025-gold-report/">here</a> for the 2025 GOLD report to learn more about COPD exacerbation diagnosis and severity.
&nbsp;
<h3>Differentiating asthma and COPD exacerbations9&nbsp;</h3>
Both asthma and COPD are obstructive lung disorders characterized by reduced pulmonary airflow due to increased inflammation and may present with acute exacerbations. Although the two conditions show some overlap in clinical features, the guideline-recommended management strategies and goals are different for both. Thus, it is important to distinguish between them for accurate diagnosis.&nbsp;
&nbsp;
COPD and Asthma: Distinguishing features9

<h2>Treatment for acute COPD exacerbation</h2>
Minimizing the negative impact of ongoing COPD exacerbations and reducing the number and COPD exacerbation severity is critical to COPD management.10&nbsp;

Approximately four in five exacerbations are managed in outpatient setting using bronchodilators, corticosteroids and antibiotics.2 On arrival in emergency department, it should be assessed if the episode is life threatening and/or requires noninvasive ventilation.2&nbsp;
A life-threatening episode presents with signs of acute respiratory failure (respiratory rate, &gt;24 breaths/minute; use of accessory respiratory muscles; acute changes in mental status; hypoxemia not improving with supplemental oxygen and requirement of FiO2 &gt;40%; hypercarbia).2 Such patients should be admitted in a setting where they can be properly monitored and managed.2
&nbsp;
Management of severe, but not life-threatening exacerbations2

Learn more about the <a href="https://goldcopd.org/2024-gold-report/">GOLD recommendations for treatment and management of COPD</a>.
&nbsp;
<h4>COPD exacerbation guidelines for treatment</h4>
Please find below key recommendations by the European Respiratory Society (ERS) and American Thoracic Society (ATS) for the management of COPD exacerbations.&nbsp;
&nbsp;
<h3>Key ERS/ATS recommendations for COPD exacerbation12</h3>

The GOLD 2025 report presents few key points for management of all COPD exacerbations.2
&nbsp;
Key points for management of all COPD exacerbations2

Acute COPD exacerbations are linked to significant disease progression. Uncover criteria, symptoms, and treatment guidance to manage them in your patients.

Understanding and Managing COPD Exacerbations

Understanding type 2 inflammation may help shed light on why some patients continue to exacerbate. Watch this video to learn how.

One minute to ignite new thinking in COPD

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Latest COPD articles

The burden and Risk of Exacerbations in COPD according to Dr. Surya Bhatt

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Understanding and Managing COPD Exacerbations