What is an Exacerbation or Flare Up?

An exacerbation (x-saa-cer-bay-shun) is a flare-up or episode when your breathing gets worse than usual and may continue to get worse without extra treatment. With COPD you may have the same daily symptoms with the same activities for weeks or months.

Then suddenly you may have a flare-up where the cough, shortness of breath, or mucus may increase, often caused by a lung infection. This can be very serious, causing you to go to the emergency room or have to stay in the hospital for a few to several days.

Exacerbations or flare ups can be kept less serious if you get help early by calling your doctor or nurse before you need to go to the emergency room or hospital.

Future exacerbations or flare ups may be prevented by:

  • Changes in medicines as prescribed by your doctor or nurse
  • Going to pulmonary rehabilitation (rehab)
  • Getting the help you may need to stop smoking/vaping
  • Getting your annual flu shot and making sure you are up to date on your other immunizations like the pneumonia shot(s), Tdap and shingles.

In addition to these prevention measures, it is important to learn the early signs of an exacerbation and what to do when they happen as part of learning to manage your COPD. The COPD Foundation's COPD Pocket Consultant Guide mobile app has a COPD Action Plan to list your warning signs and tells you what actions to take. Ask your doctor or nurse to help you fill in your COPD Action Plan.

If you would like to see what other people with COPD and health care professionals have to say about exacerbations, please see the Understanding COPD Exacerbations Survey Report for the results of a study asking people with COPD and the doctors who care for people with COPD.

Is it an Exacerbation/Flare Up or Just a Bad Day?

The first step in knowing that this may be an exacerbation or flare up is watching for changes in your usual symptoms like more shortness of breath with less activity, more cough, more mucus, and more fatigue. The quicker you know you are starting to have problems, the quicker you and your health care professional (doctor or nurse) can help you deal with it.

It is not always easy to tell the difference between a "bad day" and the start of an exacerbation or flare up, but it is important. Some things that might cause you to have a bad day are: weather, a "cold" or start of a lung infection, low pressure, emotions like stress or anxiety or depression, allergies, higher altitude, using an empty inhaler or not using a new type of inhaler correctly. An exacerbation or flare-up usually continues to get worse over the day and does not clear up with rest and a few extra puffs or nebulizer use of a quick reliever medicine like albuterol.

Early Warning Signs of An Exacerbation or Flare Up

Warning signs that a flare-up is beginning can be different for each person. Most of the time, you will know best when your breathing problems are getting worse. Your friends and family can help you notice and not ignore the early signs and symptoms so that you can get help before you need emergency help. Having all of these listed on your COPD Action Plan can make it easier to know when to call your doctor or get emergency help.

Important Early Warning Signs are:

  • Increases in cough.
  • Increase or changes in mucus.
  • More shortness of breath with the same or less activity

Other common signs and symptoms of an exacerbation or flare up are:

  • Low grade fever that doesn’t go away.
  • Increased use of rescue or quick relief inhaler or nebulizer medicines.
  • Change in color, thickness, odor, or amount of mucus.
  • Fatigue that lasts more than one day.
  • New or increased ankle swelling.
  • More wheezing.

In addition, an exacerbation may come with signs of lower oxygen in your blood:

  • Morning headaches, dizzy spells, and restlessness.
  • A need to increase your oxygen, if you are on oxygen.
  • Rapid breathing.
  • Rapid heart rate.

Call 911 for Dangerous Warning Signs

  1. Confusion, disorientation, or slurring of speech.
  2. Severe shortness of breath or chest pain. (Cannot talk or lay down because of the shortness of breath for example)
  3. Blue color in lips or fingers.

What Causes an Exacerbation or Flare Up?plus

An infection in your lungs is almost always the cause of an exacerbation. These infections may be caused by viruses or bacteria. Antibiotics (an-tee-by-ah-ticks) are medicines that can be given for an infection caused by bacteria. These drugs do not help with infections caused by viruses.

Sometimes, when a person with COPD gets an infection from a virus, they also get a second infection from bacteria. This happens because the virus has caused more mucus to be made, which has irritated the lungs. Together, this causes more bacteria to grow in the lungs. This can lead to a bacterial infection.

So, antibiotics are almost always used to treat serious exacerbations such as those that send you to the emergency room or hospital or lower your oxygen levels. Other causes of exacerbations may include sinus infections, an asthma attack, indoor and outdoor air pollution, or an allergic reaction (not usually food allergies). Severe exacerbations may also have pulmonary edema (fluid in your lungs), and blood clots in the lungs.

Know Your Heart Rate and Rate of Your Breathingplus

As a person with COPD, it is important that you know what your heart and breathing rates are when you are feeling good. These are called your "baseline" rates.

When you start to feel a flare-up coming on, take your heart rate and breathing rate. Compare these to the baseline rates. Also notice how much your heart rate and breathing rate Increase with your usual activities. They usually increase to higher rates with an exacerbation or flare up.

Knowing if your breathing and heart rates have increased will help you talk to your doctor about your flare-up. Your health care professional will use this information to help decide how to treat your exacerbation.

Counting Your Breathing Rate (Respirations):
  1. Place your hand on your upper chest to feel it rise and fall. Each rise and fall counts as one breath.
  2. Look at your watch. Count the number of breaths in one minute and this is your breathing or respiratory rate. Or just count for 30 seconds and multiply this number by two.
Counting Your Heart Rate:
  1. Find the heartbeat, or pulse, on one side of your neck. Put your index and middle fingers to the side of your throat, under your chin and about halfway to under your ear. Don’t press hard and don’t rub since that may change your heart rate.
  2. Look at your watch. Count your heartbeat for 30 seconds, then multiply by 2 or count the beats for 10 seconds and multiple by 6. This is your heartbeat in one minute.

How to Reduce Exacerbations or Flare Ups

You cannot prevent all exacerbations or flare ups, but you can work to reduce how often you have them. You can also work to reduce how serious the exacerbations or flare ups become to stay as healthy as possible.

Tips for preventing exacerbations or flare ups:
  • Handwashing is key to stopping the spread of bacteria and virus infections. Make sure you follow best practices for handwashing at https://www.cdc.gov/handwashing/when-how-handwashing.html
  • Avoid close contact with people who have colds or were diagnosed with respiratory infections like the flu or coronavirus.
  • Get a flu shot each year.
  • Ask your health care provider about a pneumonia (new-moan-ya) shot or shots and other immunizations you may need.
  • Always take your daily controller/maintenance medicines as you and your doctor have talked about.
  • Make sure you know how to use your inhalers and nebulizers. Ask the doctor, nurse or pharmacist to watch you use your inhalers.
  • Work out a COPD Action Plan with your health care professional so you know the early signs and what to do if a flare up starts.
  • Don’t wait to see if the exacerbation or flare up is going to “get bad”. Call early and get the help you need.
Things NOT to do during an exacerbation
  • Do not take cough syrups that include codeine or any type of cough suppressant (sue-press-ant).
  • Do not smoke and don’t let others smoke around you.
  • Do not wait more than 24 hours to call your health care professional (doctor or nurse) if your symptoms continue.

Have a Plan

Don’t be afraid to speak up: if your doctor or nurse does not ask about flare ups or times you’re your symptoms got worse at each visit, tell them about those times and ask what can be done to prevent them. You and your health care professional should talk about what an exacerbation or flare up is, what does it look like for you, what you can do prevent one, and how to reach your health care team including nights and weekends in case of worsening symptoms.

To make sure you have all of these answers in a handy place, you and your health care team can create a written plan (COPD ACTION PLAN) for exacerbations. This plan may include adding to, or changing, the medicines you normally take. Sometimes, people with many exacerbations may need to have medicines at home to start including antibiotics or steroids to be started according to your COPD ACTION PLAN. You may also need to increase your oxygen use.

The written action plan can help you or your family or caregiver know what to do. Some people worry that they don't want to bother their health care team or are afraid of having to go to the emergency room or hospital. The COPD ACTION PLAN can guide you. If you think about asking your health care team or you’re ACTION PLANS say it is time to call, please do so right then.

Show your health care team the My COPD Action Plan or the COPD Pocket Consultant Guide mobile app and ask if you can work together to make a plan for you to help avoid and treat exacerbations or flare ups.

Resources and Support

The COPD Foundation offers resources such as COPD360social, an online community where you can connect with patients, caregivers and health care providers and ask questions, share your experiences and receive and provide support.