Recovery Following Acute Exacerbations of Chronic Obstructive Pulmonary Disease – A Review

Figures & data

Figure 1. Definition of acute exacerbation of COPD (AECOPD). Definition for AECOPD from Seemungal et al. (3) and the definition of recovery for AECOPD from Donaldson et al. (2).

Figure 2. Recovery of lung function after AECOPD. Day 0 is onset of exacerbation. Data are mean ± SD unless otherwise stated. (a) Recovery of FEV₁ %predicted over time. (b) Recovery of FEV₁ (L) over time. FEV₁ = forced expiratory volume in one second; AECOPD = acute exacerbation of chronic obstructive pulmonary disease; n = number of participants; L = litres; %predicted = percentage of predicted normal.

Note: Data from Jetmalani et al. (74) are a combination of the means and SD from two groups presented in the study (75). Data from Kocks et al. (46) were derived from the graph, there is no SD.

Figure 3. Recovery of systemic inflammatory markers over time. Day 0 is onset of exacerbation. Data are mean ± SD, unless otherwise stated. CRP = C-reactive protein; IL-6 = interleukin-6; TNF-α = tumour necrosis factor-alpha; AECOPD = acute exacerbation of chronic obstructive pulmonary disease; pg = picograms; ml = millilitre; mg = milligram; dl = decilitre; n= number of participants. ^^data presented as median.

Table 1. Symptoms recovery in days and tools used for assessment.

Author	Sample size	Baseline FEV1 (%predicted)	Assessment tool	Assessment timeline	Symptom resolution (days)
Seemungal et al. (4)	101	41.9 ± 19.7	Total symptom score	Daily over 2.5 years	7 (4–14)
Seemungal et al. (24)	83	42.4 ± 19.8	Total symptom score	Daily over 2.5 years	8 (3–15)
Parker et al. (13)	12 (fully recovered group)	44.2 ± 2.0 (n = 20)	Participants were asked if their dyspnoea had returned to their pre-exacerbation level	Days 0 (within 72h admission), 14, 30 and 60	41 ± 6
Perera et al. (11)	73	45 ± 18.0	Total symptom score: was binary coded as one (present or increased over baseline) or zero (absent or not increased) and then summed.	Daily until 50 days after onset of exacerbation	9 (4–18)
Koutsokera et al. (8)	35	38.5 ± 3.5	Total symptom score: derived from the sum of five symptoms (dyspnoea, cough, sputum production, wheezing and night-time awakenings), each of which was assessed with a modified Borg scale	Days 0 (admission), 3, 10 and 40	10^a
Chang et al. (21)	93	47 ± 43.6	Dyspnoea using: mMRC.	Days 0, 4, 7 14 and 8 weeks	4^a
Alahmari et al. (25)	73	52.9 ± 16.5	Total symptom score: obtained by summating each increased respiratory symptom recorded on diary cards per day	Daily for at least 35 days	11 (8–17)
Donaldson et al. (2)	334	45.7 ± 16.6	Total symptom score	Daily for at least 365 days	10 (6–18)

Data are mean ± SD or median (25th to 75th percentile) except where indicated.

^aDay of assessment that symptoms were recovered.

FEV₁: forced expiratory volume in one second; %pred: % predicted; mMRC: modified Medical Research Council questionnaire; h: hours; Total symptom score is the sum of presence (yes = 1) and absence (no = 0) of seven respiratory symptoms.

Figure 4. Recovery of health-related quality of life during following AECOPD. Baseline indicates pre-exacerbation data. Day 0 is onset of exacerbation. Data expressed as mean ± SD unless otherwise stated. (a) Demonstrates the recovery curve measured by CAT score. (b) Demonstrates the recovery curve measured by SRGQ score.

SGRQ score = Saint George’s Respiratory Questionnaire; CAT score = chronic obstructive pulmonary disease assessment test score; AECOPD = acute exacerbation of chronic obstructive pulmonary disease; n = number of participants; QoL: Quality of life.

Note: Ansari et al. (47) presented only results from the hospitalised participants group. Data from Kocks et al. (46), Mackay et al. (39) and Chang et al. (23) were extracted from the graph.

Table 2. Factors associated with prolonged recovery from an AECOPD.

Characteristic associated with delayed recovery	Study	Relationship
Demographic features
Older age	Liang et al. (9)	Older age predicted non-recovery OR 1.029 (95% CI 1.016–1.042)
More severe lung disease	Donaldson et al. (2)	Annual rate of nonrecovered exacerbations increased in more severe patients by 0.0018 events/year per 1% lower FEV1 %predicted
	Koutsoukera et al. (8)	Late-recoverers had lower baseline FEV1 %predicted compared to the early-recoverers; mean 32 (SD 3) vs 47 (6) % respectively, p = 0.028
	Liang et al. (9)	Worse GOLD stage predicted non-recovery OR 1.491 (95% CI 1.256–1.770)
Lower body mass index	Liang et al. (9)	Lower BMI predicted non-recovery OR 0.951 (95% CI 0.918–0.985)
Higher levels of chronic dyspnoea	Liang et al. (9)	Worse MMRC predicted non-recovery OR 1.352 (95% CI 1.189–1.539)
Chronic bronchitis	Liang et al. (9)	Recovery was longer in patients with chronic bronchitis (mean 19 (SD 16) vs 15(14) days, p = 0.003)
Exacerbation features
Symptoms of common cold on day of exacerbation onset	Donaldson et al. (2)	38% of those with prolonged recovery vs 30% without
	Seemungal et al. (4)	Increased recovery time by 2.5 days (95% CI 1.8–3.3)
Sore throat on day of exacerbation onset	Donaldson et al. (2)	18% of those with prolonged recovery vs 12% without
Persistent systemic inflammation	Perera et al. (11)	Patients without symptom recovery at day 35 had a persistently higher serum CRP compared with those patients who had recovered (p = 0.03).
Severity of exacerbation symptoms	Seemungal et al. (4)	Higher levels of dyspnoea at exacerbation onset increased recovery time mean 3.31 days (95% CI 2.65–3.98).
Viral infection	Seemungal et al. (24)	Recovery of symptoms in those with viral infection was median 13 days (IQR 5–20 days) vs 6 days (3–13 days) in those without

BMI: body mass index; CI: confidence interval; CRP: C-reactive protein; FEV1: forced expiratory volume in one second; GOLD: Global initiative for Obstructive Lung Disease; IQR: interquartile range; MMRC: modified Medical Research Council scale; OR: odds ratio.

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