COPD Exacerbation


Paul Sarmiento, MD


Prior Diagnosis of COPD?

Dyspnea: Progressive? Worse with exercise? Persistent? Air Hunger?

Chronic cough: intermittent? May be unproductive

Chronic sputum production: any pattern of chronic sputum may indicate COPD

History of exposure to risk factors: Tobacco? Occupational dusts/chemicals? Smoke from home cooking and heating fuel?

Chronic medications? Home oxygen therapy? Exacerbation frequency? Last steroid dose?


Prior Spirometric classification of COPD Severity based on Post-Bronchodilator FEV1




I: Mild COPD

FEV1/FVC < 70%

FEV1≥ 80% predicted

Short acting bronchodilator

II: Moderate COPD

FEV1/FVC <70%

50% ≤ FEV1 <80% predicted

Add regular treatment with one or more long-acting bronchodilator; add rehabilitation

III: Severe COPD

FEV1/FVC < 70%

30% ≤ FEV1 < 50% predicted

Add inhaled glucocorticosteroids if repeat exacerbations

IV: Very Severe COPD

FEV1/FVC < 70%

FEV1 < 30% predicted or

FEV1 < 50% predicted plus chronic respiratory failure

Add long term oxygen if chronic respiratory failure

Consider surgical options


Is this a COPD exacerbation?

Increased breathlessness? With Wheezing? Chest tightness? Increase in baseline cough frequency? Dyspnea? Change in Sputum – color? Texture? Acute in onset?

Most common cause of an exacerbation are infection of the traceobroncial tree and air pollution, but the cause of ~1/3 of severe exacerbations cannot be identified.


Any clinical signs of airway infection?

Increased sputum? Increased sputum purulence? Fever?

Recent investigations have shown that at least 40% of patients have bacteria in high concentrations in their lower airways during exacerbations. Most common pathogens include Streptococcus pneumonia, Hemophilus influenzae, Moraxella catarrhalis


Other Findings?

Tachycardia? Tachypnea? Malaise? Insomnia? Sleepiness? Fatigue? Depression? Confusion? Any mental status change?


Assessing severity:

Assess past medical history before exacerbation, preexisting comorbidities, severity of symptoms. What is the frequency/severity of prior exacerbations?


Check: Blood gas, CXR, ECG, Pulse Ox, CBC, Electrolytes, Glucose, Acid-base disorder


Spirometry, PFTs are not accurate during an acute exacerbation and routine use is not recommended.


ABG Indications of Respiratory Failure:

PaO2 < 60 mm Hg on RA

SaO2 < 90% with or without  PaCO2 > 50 on RA


Acidosis pH < 7.36 + Hypercapnia PaCO2 > 45-60 with respiratory failure is an indication for mechanical ventilation


Always consider PE in your differential.

Especially if PaO2 does not increase despite high-flow oxygen

Differential includes pneumonia, CHF, PTX, pleural effusion, cardiac arrhythmias,



Risk of dying is proportional to respiratory acidosis, significant comorbidities, ventilatory support.  Patients without these factors are not at high risk for dying.


Level of Care Considerations:


Indications for Hospital assessment or admission


Indications for ICU admisstion


First Actions:

Oxygen Therapy; Goal SaO2 > 90%, PaO2 > 60;

Venturi masks (high-flow) deliver oxygen better than nasal prongs but are less tolerable.

Determine if exacerbation is life threatening; consider ICU admission if appropriate


Next Steps:

Once oxygen started, check ABG in 30-60 min.

Check: Blood gas, CXR, ECG, Pulse Ox, CBC, Electrolytes, Glucose, Acid-base disorder



Short acting inhaled B-agonists (evidence A)

Albuterol MDI 100-200 mcg QID

Albuterol Nebulizer 0.5-2.0 mg QID

Albuterol Pill PO 4 mg BID



Ipratropium Bromide MDI 18-36 ug QID

Ipratropium Bromide Nebulizer 0.5 mg QID



Consider the following regimen for inpatient exacerbations**:

Methylprednisone 125 mg IV Q6H x 3 days

Methylprednisone 60 mg PO QD x 4 days

Methylprednisone 40 mg PO QD x 4 days

Methylprednisone 20 mg PO QD x 4 days


Consider for outpatient management or mild inpatient exacerbation**:

Prednisone 40mg PO QD x 2 days

Prednisone 30mg PO QD x 2 days

Prednisone 20mg PO QD x 2 days

Prednisone 10mg PO QD x 2 days



TMP-SMX 160/800 mg BID x 5-10 days

Amoxicillin 250 mg PO QID x 5-10 days

Doxycycline 100 mg PO, 2 tablets day 1, 1 tablet/day for 5-10 days

(some authors suggest all should be 10-day course)


Other options:

Methyxanthines such as aminophylline, theophylline


Studies suggest that two-week systemic glucocorticoid regimens that begin with either high-dose or low-dose initial therapy can improve clinical outcomes in hospitalized patients. The optimal initial dose remains to be determined, since the two studies used somewhat different methodologies, and high versus lower-dose regimens have not been directly compared. The outcomes of the two studies show that early FEV1 improvements were greater in the study which used an initial regimen of IV methylprednisolone 125 mg every six hours [3]; however, an initial regimen of 30 mg per day of oral prednisolone achieved a similar reduction in hospital length of stay [4].


Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. Niewoehner DE. N Engl J Med 1999 Jun 24;340(25):1941-7.


Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Davies L. Lancet 1999 Aug 7;354(9177):456-60.


** Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Stoller JK.  N Engl J Med 346:988, March 28, 2002



Non-invasive BIPAP, CPAP



Indications and Relative Contraindications for NI Intermittent Ventilation


Indications for Invasive Mechanical Ventilation


Discharge Criteria



Further thoughts


The impact of exacerbations is significant and a patient’s symptoms and lung function may both take several weeks to recover to baseline values.