What is an Exacerbation or Flare-up?

An exacerbation is a flare-up or episode when your breathing is worse than usual and may continue to worsen without treatment. With COPD, you may be able to participate in the same activities for weeks or months without having worsening symptoms. Then suddenly you may have a flare-up where your cough, shortness of breath, or mucus may increase. This is often caused by a lung infection. Exacerbations can be very serious, causing you to go to the emergency room or have to stay in the hospital for up to several days.

If you get help early, exacerbations may be less serious. Exacerbations or flare-ups can be kept less serious if you get help early by calling your health care provider or nurse at the first sign of worsening symptoms.

Future exacerbations or flare-ups may be prevented by:
  • Changes in medicines as prescribed by your health care provider 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. 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 health care provider 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.

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 increased 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, emotions (like stress, 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 health care provider or get emergency help.

Important Early Warning Signs are:
  • Increase 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 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, leading to a bacterial infection.

Antibiotics are often used to treat serious exacerbations such as those that lower your oxygen levels or send you to the emergency room or hospital. Other causes of exacerbations may include sinus infections, an asthma episode, indoor and outdoor air pollution, or an allergic reaction. In some cases, severe exacerbations may also lead to 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. Compare this to the baseline rate. Also notice how much your heart rate increases with your usual activities. Your heart rate and breathing rate usually increase with an exacerbation or flare-up.

While you can measure your own heart rate, it is important that a friend, family member, or loved one measure your breathing rate for you. It is helpful to have someone else count your breathing rate when you are not paying attention. Your breathing pattern may change if you are focusing on your breathing, which would not give you an accurate number.

Tell your health care providers if your breathing and heart rates have increased. Your health care professional will use this information to help decide how to treat your exacerbation.

For caregivers and family: Counting Your Loved One's Breathing Rate (Respirations):
  1. Watch your loved one's chest rise and fall. Each rise and fall counts as one breath.
  2. Look at your watch. Count the number of breaths in one minute. This is your loved one's 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 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 multiply 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 shot or shots and other immunizations you may need.
  • Always take your daily controller/maintenance medicines as you and your health care provider have talked about.
  • Make sure you know how to use your inhalers and nebulizers. Ask your health care provider, nurse, or pharmacist to watch you use your inhalers.
  • Fill out the My 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.
  • 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 (exacerbations) 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 a flare-up is, what it looks like for you, what you can do to prevent one, and how to reach your health care team (including on nights and weekends) in case of worsening symptoms.

To make sure you have all of this information in a handy place, you and your health care team can create a written plan (My COPD Action Plan) for exacerbations. This plan may include adding to, or changing, the medicines you normally take. Sometimes, your health care provider may give you medication to keep at home in case of an emergency or exacerbation. These can include antibiotics or steroids which you would use according to your My COPD Action Plan. You may also need to increase your oxygen use during exacerbations.

The My COPD Action Plan can help you and your family or caregiver know what to do on good days and bad. Some people don't want to bother their health care team or are afraid of having to go to the emergency room or hospital. The My COPD Action Plan can guide you. If you are thinking about contacting your health care team for advice, or your My COPD Action Plan says to contact them, please do so right away.

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.