Written and peer-reviewed by physicians—but use at your own risk. Read our disclaimer.

banner image

amboss

Trusted medical answers—in seconds.

Get access to 1,000+ medical articles with instant search
and clinical tools.

Try free for 5 days

Acute exacerbation of chronic obstructive pulmonary disease

Last updated: January 15, 2021

Contributor disclosures

None of the individuals in control of the content for this article (a continuing medical education activity) reported relevant financial relationships with commercial interests.

Summary

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is defined as the acute worsening of respiratory symptoms in a patient with COPD that necessitates additional therapy. The most common trigger of AECOPD is respiratory viral infection. Cardinal symptoms of AECOPD include worsening of dyspnea, increased frequency and severity of cough, and increased volume and/or purulence of sputum. AECOPD is a clinical diagnosis and the diagnostic workup serves primarily to assess the level of severity and evaluate for any underlying trigger and coexisting comorbidities. Management of AECOPD consists primarily of respiratory support, inhaled bronchodilator therapy, and systemic corticosteroids. Antibiotics should be considered in patients with severe AECOPD and patients who are mechanically ventilated. See also “COPD” and “Mechanical ventilation.”

Etiology

Clinical features

Diagnostics

General principles

  • AECOPD is a clinical diagnosis (see “Cardinal symptoms of AECOPD”).
  • The goals of diagnostic evaluation are to:
    • Identify triggers and/or complications (e.g., pneumothorax, ARDS)
    • Rule out alternate diagnoses
    • Identify comorbid diagnoses that affect management and/or prognosis (e.g., chronic respiratory acidosis)
    • Risk-stratify the severity of the exacerbation
    • Assess the response to treatment
  • Consider empiric bronchodilator therapy if the diagnosis is unclear.

Testing should not delay urgent treatment in patients presenting with signs of respiratory failure or distress if clinical criteria of AECOPD are met.

Laboratory studies [2]

  • Arterial blood gas: to assess the level of severity
  • Microbiological studies
    • Nasopharyngeal swab for respiratory virus detection (using NAAT) [5]
    • Sputum Gram stain and culture are recommended for patients with the following: [2]
  • Additional workup for alternate diagnoses and relevant comorbidities: as guided by clinical suspicion

PaCO2 on blood gas should be interpreted in relation to the patient's baseline because of chronic CO2 retention.

Imaging [2]

Imaging is not required to confirm the diagnosis but may be used to evaluate for potential triggers (e.g., pneumonia) and/or rule out other causes of dyspnea (see “Differential diagnosis of AECOPD”).

Additional testing

ECG [2]

Pulmonary function testing [2]

Spirometry is not routinely recommended in the assessment of AECOPD. [7]

  • Potential uses include:
    • Confirming the diagnosis for first-time patients (see “Diagnosis of COPD”)
    • Grading the severity of disease for prognostication [8]
  • Interpretation of changes in FEV1: [9][10][11][12]
    • Can predict poor outcomes and treatment failure
    • Correlates poorly with the risk of subsequent exacerbations

Advanced testing

Classification

The following system is recommended to classify AECOPD severe enough to require a hospital visit and is based on clinical and laboratory parameters. For baseline classification, see “COPD classification.” [2]

Classification of AECOPD [2]
Clinical or laboratory parameter AECOPD with life-threatening acute respiratory failure AECOPD with non-life-threatening acute respiratory failure AECOPD without respiratory failure
Respiratory rate
  • > 30/min
  • 20–30/min

Accessory muscle use

  • Yes
  • No

Change in baseline mental status

  • Yes
  • No

Degree of hypoxemia

Hypercapnia

  • Elevated PaCO2
    • Markedly elevated from baseline
    • OR > 60 mm Hg
  • AND/OR pH ≤ 7.25
  • Elevated PaCO2
    • Elevated from baseline
    • OR 50–60 mm Hg
  • No worsening from baseline

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

The overarching goal of treatment in AECOPD is to minimize the impact of the current exacerbation and prevent subsequent exacerbations. [2]

Approach to the management of AECOPD [2]

The ABCDE approach is indicated for all patients with respiratory distress. See “Classification of AECOPD” section for the clinical and laboratory parameters that define the following categories.

Acute exacerbation of COPD may be a life-threatening emergency. Rapid assessment is recommended to identify patients who require aggressive care and admission to ICU.

Respiratory support

Oxygen therapy

Noninvasive positive pressure ventilation (NIPPV)

NIPPV is the recommended first-line ventilatory strategy in AECOPD with acute respiratory failure. NIPPV is associated with a decreased need for intubation, decreased hospital length-of-stay, and lower mortality. [2]

Invasive mechanical ventilation

Intubation and mechanical ventilation are especially high-risk and complication-prone procedures in AECOPD, and they are generally used as a last resort (see “High-risk indications for mechanical ventilation”). [15][16]

Intubation and mechanical ventilation of patients with AECOPD carries a significant risk of periprocedural cardiac arrest due to rapid oxygen desaturation, dynamic hyperinflation, circulatory shock, and/or severe respiratory acidosis! Countermeasures should be taken prior to performing these procedures (see “High-risk indications for mechanical ventilation”).

Pharmacological therapy for AECOPD [2][17][18][19]

Overview

The following are suggested pharmacological treatment combinations based on symptom severity.

Bronchodilators

Corticosteroids

Antibiotics [2]

The routine use of antibiotics in AECOPD is controversial, but antibiotics are associated with enhanced symptom resolution and a lower risk of treatment failure in patients with moderate to severe AECOPD. [2]

Adjunctive treatment and supportive care [2]

Monitoring and disposition

Monitoring

  • Symptom surveillance and severity assessment, as clinically indicated
  • Continuous pulse oximetry
  • Serial blood gas monitoring

Indications for hospital admission [2]

  • Acute respiratory failure
  • Severe symptoms
  • New physical examination signs
  • Condition refractory to initial medical treatment
  • Significant comorbidity
  • Insufficient home/community support system

Indications for ICU admission [2]

Clinical decision tools [25]

The following assessment measures may help to objectively identify patients at risk of poor medical outcomes.

  • 3-minute walk test [26]
    • Patients undertaking the test are less likely to have a poor clinical outcome if:
      • They can complete a 3-minute walk at their own pace (with aids and/or home oxygen as needed)
      • Highest heart rate is < 120/minute
      • Lowest SpO2 is ≥ 90%
Ottawa COPD Risk Scale (OCRS) [27][28]
Parameters Points

Evaluation on arrival

Prior CABG

1

Prior intervention for PVD

1

Prior intubation for respiratory distress

2

Pulse ≥ 110/min

2

Diagnostic test results

Hemoglobin < 10 g/dL

3

BUN ≥ 34 mg/dL

1

Serum CO2 ≥ 35 mEq/L

1

Ischemic changes on ECG

2

Pulmonary congestion on CXR

1

Evaluation after initial treatment

SpO2 < 90% or pulse ≥ 120/min

2

Interpretation: A higher total score corresponds to an increased risk of serious short-term outcomes.

  • Low (0 points): 2% risk
  • Medium (1–2 points): 4–7% risk
  • High (3–4 points): 12–20% risk
  • Very high (> 5 points): 33–91% risk

Acute management checklist

Respiratory support

Medical therapy

References

  1. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). http://www.goldcopd.org. . Accessed: June 27, 2019.
  2. Ginocchio CC, McAdam AJ. Current Best Practices for Respiratory Virus Testing. J Clin Microbiol. 2011; 49 (9 Supplement): p.S44-S48. doi: 10.1128/jcm.00698-11 . | Open in Read by QxMD
  3. Harrigan RA. ABC of clinical electrocardiography: Conditions affecting the right side of the heart. BMJ. 2002; 324 (7347): p.1201-1204. doi: 10.1136/bmj.324.7347.1201 . | Open in Read by QxMD
  4. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  5. Calverley PM. Chronic Obstructive Pulmonary Disease Exacerbations and Lung Function Decline. Mechanism or Marker?. Am J Respir Crit Care Med. 2017; 195 (3): p.278-279. doi: 10.1164/rccm.201609-1837ED . | Open in Read by QxMD
  6. Watz H, Tetzlaff K, Magnussen H, et al. Spirometric changes during exacerbations of COPD: a post hoc analysis of the WISDOM trial. Respir Res. 2018; 19 (1): p.251. doi: 10.1186/s12931-018-0944-3 . | Open in Read by QxMD
  7. Niewoehner DE, Collins D, Erbland ML. Relation of FEV1to Clinical Outcomes during Exacerbations of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2000; 161 (4): p.1201-1205. doi: 10.1164/ajrccm.161.4.9907143 . | Open in Read by QxMD
  8. Crisafulli E, Torres A, Huerta A, et al. Predicting In-Hospital Treatment Failure (≤7 days) in Patients with COPD Exacerbation Using Antibiotics and Systemic Steroids. COPD: Journal of Chronic Obstructive Pulmonary Disease. 2015; 13 (1): p.82-92. doi: 10.3109/15412555.2015.1057276 . | Open in Read by QxMD
  9. Oliveira A, Machado A, Marques A. Minimal Important and Detectable Differences of Respiratory Measures in Outpatients with AECOPD†. COPD: Journal of Chronic Obstructive Pulmonary Disease. 2018; 15 (5): p.479-488. doi: 10.1080/15412555.2018.1537366 . | Open in Read by QxMD
  10. Sandhaus RA, Turino G, Brantly ML, et al. The Diagnosis and Management of Alpha-1 Antitrypsin Deficiency in the Adult. Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation. 2016; 3 (3): p.668-682. doi: 10.15326/jcopdf.3.3.2015.0182 . | Open in Read by QxMD
  11. Menendez R, Torres A. Treatment Failure in Community-Acquired Pneumonia. Chest. 2007; 132 (4): p.1348-1355. doi: 10.1378/chest.06-1995 . | Open in Read by QxMD
  12. Wu X, Chen D, Gu X, Su X, Song Y, Shi Y. Prevalence and risk of viral infection in patients with acute exacerbation of chronic obstructive pulmonary disease: a meta-analysis.. Mol Biol Rep. 2014; 41 (7): p.4743-51. doi: 10.1007/s11033-014-3345-9 . | Open in Read by QxMD
  13. Eklöf J, Sørensen R, Ingebrigtsen TS, et al. Pseudomonas aeruginosa and risk of death and exacerbations in patients with chronic obstructive pulmonary disease: an observational cohort study of 22 053 patients. Clinical Microbiology and Infection. 2020; 26 (2): p.227-234. doi: 10.1016/j.cmi.2019.06.011 . | Open in Read by QxMD
  14. Garcia-Vidal C, Almagro P, Romani V, et al. Pseudomonas aeruginosa in patients hospitalised for COPD exacerbation: a prospective study. European Respiratory Journal. 2009; 34 (5): p.1072-1078. doi: 10.1183/09031936.00003309 . | Open in Read by QxMD
  15. Goligher EC, Ferguson ND, Brochard LJ. Clinical challenges in mechanical ventilation. The Lancet. 2016; 387 (10030): p.1856-1866. doi: 10.1016/s0140-6736(16)30176-3 . | Open in Read by QxMD
  16. Mosier J, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles J. The Physiologically Difficult Airway. Western Journal of Emergency Medicine. 2015; 16 (7): p.1109-1117. doi: 10.5811/westjem.2015.8.27467 . | Open in Read by QxMD
  17. Dobler CC, Morrow AS, Beuschel B, et al. Pharmacologic Therapies in Patients With Exacerbation of Chronic Obstructive Pulmonary Disease. Ann Intern Med. 2020 . doi: 10.7326/m19-3007 . | Open in Read by QxMD
  18. Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. European Respiratory Journal. 2017; 49 (3): p.1600791. doi: 10.1183/13993003.00791-2016 . | Open in Read by QxMD
  19. Crisafulli E, Barbeta E, Ielpo A, Torres A. Management of severe acute exacerbations of COPD: an updated narrative review. Multidisciplinary Respiratory Medicine. 2018; 13 (1): p.36. doi: 10.1186/s40248-018-0149-0 . | Open in Read by QxMD
  20. Hendeles L, Hatton RC, Coons TJ, Carlson L. Automatic replacement of albuterol nebulizer therapy by metered-dose inhaler and valved holding chamber. American Journal of Health-System Pharmacy. 2005; 62 (10): p.1053-1061. doi: 10.1093/ajhp/62.10.1053 . | Open in Read by QxMD
  21. Moriates C, Feldman L. Nebulized bronchodilators instead of metered-dose inhalers for obstructive pulmonary symptoms. Journal of Hospital Medicine. 2015; 10 (10): p.691-693. doi: 10.1002/jhm.2386 . | Open in Read by QxMD
  22. Simonds A, Hanak A, Chatwin M, et al. Evaluation of droplet dispersion during non-invasive ventilation, oxygen therapy, nebuliser treatment and chest physiotherapy in clinical practice: implications for management of pandemic influenza and other airborne infections. Health Technol Assess (Rockv). 2010; 14 (46): p.131-172. doi: 10.3310/hta14460-02 . | Open in Read by QxMD
  23. Dissanayake S, Suggett J. A review of the in vitro and in vivo valved holding chamber (VHC) literature with a focus on the AeroChamber Plus Flow-Vu Anti-static VHC. Therapeutic Advances in Respiratory Disease. 2018; 12 : p.175346581775134. doi: 10.1177/1753465817751346 . | Open in Read by QxMD
  24. Stoller JK. Acute Exacerbations of Chronic Obstructive Pulmonary Disease. N Engl J Med. 2002; 346 (13): p.988-994. doi: 10.1056/nejmcp012477 . | Open in Read by QxMD
  25. Ding Z, Li X, Lu Y, et al. A randomized, controlled multicentric study of inhaled budesonide and intravenous methylprednisolone in the treatment on acute exacerbation of chronic obstructive pulmonary disease. Respir Med. 2016; 121 : p.39-47. doi: 10.1016/j.rmed.2016.10.013 . | Open in Read by QxMD
  26. Evensen AE. Management of COPD exacerbations.. Am Fam Physician. 2010; 81 (5): p.607-13.
  27. Budde J, Agarwal P, Mazumdar M, Yeo J, Braman SS. Can an Emergency Department Observation Unit Reduce Hospital Admissions for COPD Exacerbation?. Lung. 2018; 196 (3): p.267-270. doi: 10.1007/s00408-018-0102-1 . | Open in Read by QxMD
  28. Pharmacologic and Nonpharmacologic Therapies in Adult Patients With Exacerbation of COPD: A Systematic Review.
  29. Stiell IG, Clement CM, Aaron SD, et al. Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study. Can Med Assoc J. 2014; 186 (6): p.E193-E204. doi: 10.1503/cmaj.130968 . | Open in Read by QxMD
  30. Pan AM, Stiell IG, Clement CM, Acheson J, Aaron SD. Feasibility of a structured 3-minute walk test as a clinical decision tool for patients presenting to the emergency department with acute dyspnoea. Emergency Medicine Journal. 2009; 26 (4): p.278-282. doi: 10.1136/emj.2008.059774 . | Open in Read by QxMD
  31. Stiell IG, Perry JJ, Clement CM, et al. Clinical validation of a risk scale for serious outcomes among patients with chronic obstructive pulmonary disease managed in the emergency department.. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2018; 190 (48): p.E1406-E1413. doi: 10.1503/cmaj.180232 . | Open in Read by QxMD
  32. Kocak AO, Cakir Z, Akbas I, et al. Comparison of two scores of short term serious outcome in COPD patients. Am J Emerg Med. 2019 : p.158376. doi: 10.1016/j.ajem.2019.158376 . | Open in Read by QxMD
  33. Abdo WF, Heunks LM. Oxygen-induced hypercapnia in COPD: myths and facts. Crit Care. 2012; 16 (5): p.323. doi: 10.1186/cc11475 . | Open in Read by QxMD
  34. Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J.. 2017; 50 (2): p.1602426. doi: 10.1183/13993003.02426-2016 . | Open in Read by QxMD
  35. Davidson AC, Banham S, Elliott M, et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016; 71 (Suppl 2): p.ii1-ii35. doi: 10.1136/thoraxjnl-2015-208209 . | Open in Read by QxMD
  36. Criner GJ, Bourbeau J, Diekemper RL, et al. Prevention of Acute Exacerbations of COPD. Chest. 2015; 147 (4): p.894-942. doi: 10.1378/chest.14-1676 . | Open in Read by QxMD