Should a patient with influenza (flu) and chronic obstructive pulmonary disease (COPD) go to the emergency room (ER)?

Should a Patient with Influenza and COPD Go to the Emergency Room?

A patient with influenza and COPD should go to the emergency room if they exhibit any warning signs including shortness of breath at rest or with minimal activity, painful or difficult breathing, coughing up bloody sputum, confusion or disorientation, respiratory rate >30/min, blood pressure <90/60 mmHg, bilateral chest signs suggesting pneumonia, or failure to improve within 48 hours of starting antiviral therapy. 1

Risk Stratification Framework

Patients with COPD and influenza are at high risk for hospitalization and death due to influenza-related respiratory complications. 1 The decision to seek emergency care should be based on specific clinical criteria rather than the diagnosis alone.

Immediate ER Referral Indicators

Go to the ER immediately if any of the following are present:

• Respiratory distress: Shortness of breath at rest or while doing very little activity 1
• Painful or difficult breathing 1
• Hemoptysis: Coughing up bloody sputum 1
• Altered mental status: Drowsiness, disorientation, or confusion 1
• Vital sign abnormalities: Respiratory rate >30/min or blood pressure (systolic <90 mmHg or diastolic <60 mmHg) 1
• Bilateral chest signs: Crackles on both sides suggesting pneumonia, which may indicate primary viral pneumonia with a rapid and fulminant course 1

Consider Hospital Referral If:

Use the CRB-65 severity assessment tool to guide the decision: 1

• CRB-65 score of 1-2: Consider hospital referral, particularly with a score of 2 1
• CRB-65 score of 3-4: Urgent hospital referral required 1
• Any CRB-65 score with bilateral chest signs: Consider hospital referral 1

CRB-65 scoring (1 point for each): Confusion, Respiratory rate >30/min, Blood pressure <90/60 mmHg, age ≥65 years 1

Worsening of Pre-existing COPD

Patients experiencing clinical deterioration or acute exacerbation of COPD triggered by influenza should be promptly reassessed and considered for hospital referral. 1 This group is at particularly high risk of hospitalization or death. 1

Treatment Failure Indicators

Seek medical re-evaluation if:

• Fever persists for 4-5 days without improvement or worsening 1
• Initial improvement followed by high fever and feeling unwell again 1
• No improvement within 48 hours of starting antiviral drugs (oseltamivir should produce improvement within 2 days) 1
• Any rapid deterioration following initial consultation 1

Home Management May Be Appropriate If:

Patients with mild symptoms, stable vital signs, CRB-65 score of 0, adequate social support, and ability to access follow-up care may be managed at home. 1, 2 However, close monitoring is essential, and patients should be instructed on warning signs that require immediate ER evaluation. 1

Critical Pitfalls to Avoid

Do not delay seeking emergency care based solely on having started antiviral therapy - antivirals reduce severity but do not eliminate the risk of complications in COPD patients. 3, 4

Do not underestimate the risk - influenza in COPD patients is associated with increased risks of pneumonia (RR 1.77), respiratory failure (RR 1.10), COPD acute exacerbation (RR 1.34), and ischemic stroke (RR 1.13). 4

Clinical judgment supersedes any scoring system - social circumstances, baseline functional status, and access to care must be factored into the decision. 1

Patients with severe airflow obstruction (FEV1 <50% predicted) are at particularly high risk and should have a lower threshold for ER evaluation. 1, 5