Exacerbations of chronic obstructive pulmonary disease (COPD) are an important cause of the considerable morbidity and mortality found in COPD and an important cause of hospital admission . Some patients are prone to frequent exacerbations that have considerable impact on quality of life and activities of daily living . COPD exacerbations are also associated with increased airway inflammatory changes  that are caused by a variety of factors such as viruses, bacteria and possibly common pollutants (Fig. 15.1). COPD exacerbations are commoner in the winter months and thus are an important cause of hospital admission and pressures on hospital beds occurring at that time .
How is a COPD exacerbation defined?
Definitions of exacerbations are important especially for standardization in intervention studies. Although there is no standardized definition of a COPD exacerbation, an exacerbation is often described as an acute worsening of respiratory symptoms. However, some symptoms are more important in the description of an exacerbation than others and Anthonisen and colleagues pointed out that the most important symptoms of exacerbations were increased dyspnoea, sputum volume and purulence . Definitions based on symptoms have been used in other studies [2-4]. Other definitions of exacerbations have been based on health care utilization, e.g. unscheduled physician visits, changes or increases in medication, use of oral steroids at exacerbation and hospital admission, or using the combination of worsening of symptoms and health care utilization . However, health care utilization in COPD varies widely and thus there may be considerable difficulty in standardizing such a definition.
How often do patients report COPD exacerbations?
A cohort of moderate to severe COPD patients was followed in East London,
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