• Gavin C Donaldson, Martin Law, Beverly Kowlessar, Richa Singh, Simon E Brill, James P Allinson, and Jadwiga A Wedzicha.
• 1 Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and.
• Am. J. Respir. Crit. Care Med. 2015 Oct 15; 192 (8): 943-50.

RationaleExacerbations are important and heterogeneous events in the natural history of chronic obstructive pulmonary disease (COPD).ObjectivesTo examine the consequences of prolonged exacerbation recovery in patients with COPD.MethodsA cohort of 384 patients with COPD (FEV1 % predicted 45.8 [SD, 16.6] and a median exacerbation rate of 2.13 per year [interquartile range, 1.0-3.2]) were followed for 1,039 days (interquartile range, 660-1,814) between October 1995 and January 2013. Patients recorded daily worsening of respiratory symptoms and peak expiratory flow (PEF), and when stable underwent spirometry every 3 months, and completed the St. George's Respiratory Questionnaire annually. Exacerbations were diagnosed as 2 consecutive days with one major symptom plus another respiratory symptom. Exacerbation duration was defined as the time from onset to the day preceding 2 consecutive symptom-free days and recovery in PEF as return to preexacerbation levels.Measurements And Main ResultsA total of 351 patients had one or more exacerbations. Patients with a longer symptom duration (mean, 14.5 d) had a worse St. George's Respiratory Questionnaire total score (0.2 units per 1 day; P = 0.040). A longer symptomatic duration was associated with a shorter interval between exacerbation recovery and onset of the next exacerbation (hazard ratio, 1.004; P = 0.013). For 257 (7.3%) exacerbations, PEF did not recover within 99 days. These exacerbations were associated with symptoms of a viral infection (cold and sore throat). Patients with these nonrecovered exacerbations showed a 10.8 ml/yr (P < 0.001) faster decline in FEV1.ConclusionsProlonged exacerbation symptomatic duration is associated with poorer health status and a greater risk of a new event. Exacerbations where lung function does not recover are associated with symptoms of viral infections and accelerated decline in FEV1.

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