Chronic Obstructive Pulmonary Disease Exacerbations: Better Standards – Better Prognosis?

rameters: the length of stay (LOS) in hospital, the need for noninvasive or invasive ventilation, the level of disability after discharge, and death. The authors were able to demonstrate that the diagnosis of pneumonia was unexpected, based on clinical grounds, and would easily have been missed if not detected by chest X-ray. In this study, 16% of the patients with AECOPD showed pulmonary infiltrates consistent with pneumonia on chest X-rays even though patients with predominant clinical signs of pneumonia upon admission were excluded. Consistent with these findings, a recent overview of hospitalizations of COPD patients in the USA showed that pneumonia was a frequent second diagnosis (22%) in AECOPD patients upon admission [9] . In this survey, 822,500 hospital-admitted patients with COPD exacerbations had on average a hospital stay of 4.3 days. In the study of Myint et al. [8] , the LOS was markedly increased to 7–14 days in AECOPD patients with concomitant radiological findings of pneumonia. Although patients with concomitant infiltrates were more likely to suffer from comorbidities and a higher level of disability, radiological detection of pneumonia was still an independent risk factor for a longer hospital stay. This is in accordance with a Finnish registry cohort [10] where a secondary diagnosis of pneumonia in elderly COPD patients increased the LOS to up to 14.7 days. LOS is an important risk factor for hospiChronic obstructive pulmonary disease (COPD) is one of the most important noncommunicable chronic respiratory diseases [1] . In recent years, acute exacerbations of COPD (AECOPD) have been identified as major modifiers of the course of the disease [2–4] . Exacerbations requiring admission to hospital, which might occur in moderate to severe COPD, are the major threats of poor survival [5, 6] . Both the number and severity of exacerbations determine poor outcome. In addition, the severity of an exacerbation increases the risk of relapse and readmission to hospital [3] . Although the need for hospital admission is high in severe COPD (70% of all exacerbations), patients with moderate COPD also require hospital admission. COPD management recommendations therefore focus on the reduction of AECOPD via prevention and treatment strategies. In clinical practice, the diagnosis of exacerbations relies on the spirometry-proven diagnosis of COPD and the increase of symptoms of dyspnea, sputum color and quantity, and cough. The assessment of the severity of an exacerbation needs a thorough medical history and additional diagnostic tests like blood gas analysis and X-ray [7] . In this issue of Respiration , the paper of Myint et al. [8] shows that concomitant infiltrates in AECOPD, suspected as pneumonia, worsen various important outcome paPublished online: July 19, 2011