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Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a clinical diagnosis characterized by worsening respiratory symptoms within a period of 14 days. The most common trigger is a viral upper respiratory tract infection (URTI). Cardinal symptoms of AECOPD are worsening dyspnea, increased frequency and severity of cough, and increased volume and/or purulence of sputum. Testing is aimed at assessing severity, evaluating for underlying triggers, and identifying coexisting conditions (e.g., pneumonia). Respiratory support (e.g., oxygen therapy, noninvasive positive pressure ventilation) may be required to treat hypoxemia and hypercapnia. The mainstays of pharmacological therapy are bronchodilators and systemic glucocorticoids. Antibiotics should be considered in certain patients with cardinal symptoms of AECOPD (especially an increase in the purulence of sputum) and those who require mechanical ventilation.
- Viral respiratory infections: most common cause of AECOPD 
- Bacterial infections: e.g., Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae
- Additional triggers: drugs (e.g., beta blockers), allergens, air pollution, stress, pulmonary embolism
- Risk factors: previous history of exacerbations, advanced GOLD grade 
Obtain history of smoking and environmental exposure in all patients with AECOPD. 
- Cardinal symptoms of AECOPD 
- Possible additional symptoms
- Signs of AECOPD with life-threatening acute respiratory failure 
AECOPD is a clinical diagnosis; testing is aimed at assessing severity, identifying triggers, and ruling out complications and/or alternative diagnoses.
- Obtain pulse oximetry to assess oxygenation.
- Consider chest imaging to rule out pneumonia.
- Obtain microbiological studies to identify triggers.
- Consider additional studies to exclude complications and/or .
Acute respiratory conditions (e.g., pneumonia, pulmonary embolism) can be a cause, consequence, or comorbidity of AECOPD or may have a similar manifestation. Determining the sequence of symptoms is essential to avoid misdiagnosis.
Initial studies 
Risk stratification 
The following tests can help.
- Pulse oximetry: adequate for assessing oxygenation in most patients
Blood gas analysis
- ABG: to assess for hypoxemia, hypercapnia, and/or acidemia
- VBG is an acceptable alternative to ABG for estimating pH but not for assessing systemic oxygenation.
- Routine laboratory studies: CRP level ≥ 10 mg/L may indicate moderate or severe exacerbation.
Chest imaging 
- Chest CT: may be considered in addition to CXR in certain patients, e.g., those with fever, a history of heart disease, or severe emphysema
- Thoracic ultrasound: may be used to assess for pulmonary edema, pneumothorax, pneumonia, and pleural effusion (see “POCUS in acute heart failure”)
Microbiological studies 
- Testing for viral URTIs: Choose tests, e.g., nasopharyngeal swab for and/or COVID-19 testing, based on local infection patterns. 
- Sputum Gram stain and culture 
Additional studies 
Obtain additional studies based on clinical suspicion.
- D-dimer, CTA chest , e.g.,
- BNP/NT-proBNP, echocardiography , e.g.,
- cardiac arrhythmias, e.g., ECG , troponin  and
- CBC to assess for anemia , e.g.,
- Serum vitamin D level: Obtain in all patients hospitalized with AECOPD. 
Pulmonary function testing is not routinely recommended during acute exacerbations. 
See “” for baseline classification.
Classification in primary care settings (Rome proposal) 
|Classification of AECOPD severity in primary care settings|
|Severity||Mild AECOPD||Moderate AECOPD||Severe AECOPD|
Research to validate the thresholds of clinical variables is ongoing. Use clinical judgment when determining the severity of an exacerbation. 
Classification in hospitalized patients 
|Classification of AECOPD severity in hospitalized patients |
|AECOPD without respiratory failure||AECOPD with non-life-threatening acute respiratory failure||AECOPD with life-threatening acute respiratory failure|
|Clinical parameters|| || |
| || |
Evaluate and treat patients simultaneously while assessing disease severity and the response to stabilization measures. Rapidly identify indications for ICU admission in AECOPD and any patients who require aggressive therapy.
- Oxygen therapy as needed to maintain SpO2 88–92%
- Start .
- Consider indications for hospital admission in AECOPD, e.g., insufficient home/community support or severe symptoms.
- Continuously assess treatment response.
Patients with severe AECOPD
- Perform ABCDE survey.
- Maximize pharmacotherapy for AECOPD.
- Assess for .
- Obtain serial ABGs.
- If patients have hypercapnia and/or persistent hypoxemia:
- Provide supplemental oxygen for patients with hypoxemia.
- 88–92%: 
- Choose an oxygen delivery device.
- Check blood gases frequently to ensure appropriate level of oxygenation and monitor for oxygen-induced hypercapnia (CO2 narcosis).
- Indications for NIPPV in patients with AECOPD 
Indications for intubation in AECOPD 
- NIPPV is not tolerated or is inadequate, e.g., persistent respiratory acidosis or worsening mental status.
- Life-threatening hypoxemia
- Severe hemodynamic instability
- Impaired airway protection, e.g., in patients with:
- Persistent inability to clear respiratory secretions
- Important considerations
- Postintubation management
Intubation and mechanical ventilation of patients with AECOPD carry a significant risk of periprocedural cardiac arrest due to rapid oxygen desaturation, dynamic hyperinflation, circulatory shock, and/or severe respiratory acidosis.
Bronchodilators for AECOPD 
- Indication: : all patients with AECOPD
- Regimens (off-label)
- Routes of administration: MDIs and nebulizers are equally effective for drug delivery. 
Titrate dosage and frequency of medication to clinical effect and follow any local institutional protocols. Some sources recommend dosing SABA as frequently as every 20 minutes during severe AECOPD. 
Consider glucocorticoids in all patients with AECOPD.
- Route of administration
- Agents 
- Duration: 5 days 
There is no consensus on the routine use of antibiotics for the treatment of AECOPD. Some studies have shown an association with faster symptom resolution and a decreased risk of treatment failure. 
- Indications for empiric antibiotic therapy in AECOPD 
- Route of administration: Oral route is preferred if possible. 
- Duration: usually 5 days 
Before stabilization 
- Manage comorbidities, e.g., heart failure, pulmonary embolism.
- Provide VTE prophylaxis for hospitalized patients. 
- Supplement vitamin D in patients with confirmed severe (< 10 ng/mL). 
After stabilization 
- Initiate or continue , e.g., .
- Start or continue .
- Educate patients on proper inhaler technique. 
- Describe and demonstrate when prescribing a new inhaler.
- Identify common errors, e.g., inadequate exhalation prior to inhalation.
- Recommend avoidance of triggers (e.g., beta blockers, indoor air pollution).
More than 80% of patients with AECOPD are treated as outpatients. 
Indications for hospital admission in AECOPD 
- Acute respiratory failure
- Severe symptoms
- New physical examination signs, e.g., cyanosis, edema
- Condition refractory to initial medical treatment
- Significant comorbidity
- Insufficient home/community support system
Indications for ICU admission in AECOPD 
- Life-threatening acute respiratory failure
- Severe dyspnea refractory to aggressive medical treatment
- Hemodynamic instability requiring vasopressors
Discharge from hospital settings 
- Consider discharge following admission or period of ED observation in patients with all of the following:
- Consider using objective measures to guide disposition decisions, e.g.:
- Ensure the following prior to discharge:
- Patient education
- Recommended immunizations for COPD are up-to-date.
- Home care resources and social support are adequate.
- Arrangements for are made if are present.
- Outpatient follow-up within one week is scheduled. 
Clinical decision tools 
The following assessment measures may help to objectively identify patients at risk of poor medical outcomes.
- 3-minute walk test 
|Ottawa COPD risk scale (OCRS) |
Evaluation on arrival
Prior intervention for PVD
Pulse ≥ 110/min
|Diagnostic test results|| |
Hemoglobin < 10 g/dL
BUN ≥ 34 mg/dL
Serum CO2 ≥ 35 mEq/L
|Evaluation after initial treatment|| |
Interpretation: A higher total score corresponds to an increased risk of serious short-term outcomes.
- Offer supplemental oxygen to maintain target SpO2 of 88–92%.
- Monitor symptoms and treatment effects.
- Continuous pulse oximetry
- Serial blood gas monitoring
- Provide respiratory support as needed.
- Trial NIPPV before intubation (if applicable).
- Check for indications for intubation in patients with AECOPD.
- Consider admission to ICU for deteriorating patients.
- Start pharmacological therapy for AECOPD.
- Consider indications for antibiotics in AECOPD.
- Identify and treat the underlying cause.
- Provide supportive care.