Case Study : Respiratory

165. Acute exacerbation of COPD

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Breathlessness with exertion

Presentation : A 66-year-old woman visits the practice complaining of increasing phlegm production with breathlessness, worsening over the past 3 days.

She normally only gets breathless if walking uphill, but is now breathless walking on level ground.

She managed to quit smoking 2 years ago after previously smoking 10 cigarettes per day for over 50 years.

On auscultation there is reduced air entry throughout the chest with a few scattered crackles


The IMPRESS algorithm is designed to assist clinicians during the initial assessment of a patient presenting with acute or chronic breathlessness and is intentionally broad-based because of the large number of possible diagnoses.(1) 

These algorithms reflect that a patient may well have more than one condition contributing to the symptom of breathlessness and the existence of terms such as ‘cardiac asthma’ demonstrates that it is very easy to be led astray by symptoms more typical of other causes.

Important aspects of a clinical assessment of breathlessness

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This patient has an infective exacerbation of COPD and there is no clinical suggestion of pneumonia.


If basic observations, including pulse and oxygen saturations, are within the normal range it is appropriate to treat the patient in the community.

If the patient has had repeat exacerbations, it would be worth ensuring there is no suggestion of malignancy, using a chest X-ray in the first instance.



In addition to maximising inhaled short-acting bronchodilators (beta2 -agonists, with or without anticholinergics) for this moderate exacerbation of COPD, prescription of a 5–7 day course of both prednisolone 40 mg and an appropriate antibiotic is warranted.(2)


Interval follow up is important to ensure the patient returns to their usual level of symptoms and allows for assessment of other contributory conditions, such as heart failure, if the patient does not recover to their usual level of function.

Promotion of the influenza vaccine early in the season can help to prevent winter exacerbations and reduce hospital admissions.(3)


Pulmonary rehabilitation: (4)

  • should be made available to people with COPD where appropriate, including those who have had a recent hospitalisation for an acute exacerbation

  • should be offered to all patients who consider themselves functionally disabled by COPD (usually modified Medical Research Council [mMRC] scale grade 3 and above)

  • is not suitable for patients who

    • are unable to walk

    • have unstable angina

    • have had a recent myocardial infarction

Clinical outcome

This patient responded quickly to treatment over the following 48 hours.


Her COPD symptoms, breathlessness, and spirometric measurements returned to their usual levels and remained stable for the subsequent year.


She attributes the stability of her symptoms to having succeeded in stopping smoking.


Modified Medical Research Council (mMRC) Dyspnea Scale 

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1. Acute breathlessness assessment

Improving and Integrating Respiratory Services in the NHS (IMPRESS).

The Health Foundation,




2. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease

Global Initiative for Chronic Obstructive Lung Disease (GOLD) - 2017 report.

GOLD, 2016


3. Influenza vaccine for patients with chronic obstructive pulmonary disease.

Poole P, Chacko E, Wood-Baker R, Cates C.

Cochrane Database Syst Rev 2006


4. Chronic obstructive pulmonary disease in over 16s: diagnosis and management.

NICE Clinical Guideline CG101.

June 2010.


Breathlessness: what's the diagnosis?

Dr Chris Cooper

Guidelines in practice

October 2017


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