COPD exacerbation: workup and management
Acute COPD exacerbation: worsening dyspnea, cough or sputum beyond day-to-day variation. Treat with bronchodilators, a short steroid course, antibiotics when sputum is purulent, controlled oxygen, and NIV for hypercapnic acidosis.
Working diagnosis
Adult · US guidelines
Draft · awaiting physician review
01Orient
What's new in the evidence
- GOLD 2026: exacerbation severity graded by findings at presentation (dyspnea, RR, HR, SpO₂, CRP, blood gas) rather than by the treatment given
- After a severe exacerbation, start triple inhaled therapy (LAMA/LABA/ICS if eosinophils ≥100), refer to pulmonary rehabilitation and follow up within 1 month
- Biologics (dupilumab, mepolizumab) for exacerbation-prone COPD with eosinophilia; ensifentrine for persistent dyspnea
Differential diagnoses
- Viral or bacterial exacerbation
- Pneumonia
- Pulmonary embolism
- Heart failure
- Pneumothorax
- ACS or arrhythmia
- Medication non-adherence or inhaler technique failure
02Assess
Risk scores and decision tools
- GOLD 2026 exacerbation severity (mild, moderate, severe)
- DECAF score for in-hospital mortality
- Blood eosinophils to guide ICS
- Blood gas pH and PaCO₂ for NIV
Key history questions
- Change in dyspnea, sputum volume and purulence
- Baseline exercise tolerance, home oxygen
- Prior exacerbations, ICU admissions, intubations
- Current inhalers and technique
- Smoking status
Examination findings
- RR, accessory muscles, ability to speak
- Wheeze, silent chest
- Drowsiness or asterixis (hypercapnia)
- Signs of right heart failure
03Investigate
Initial investigations
- Arterial or venous blood gas
- Chest X-ray
- ECG
- CBC, BMP
- Viral testing in season
Advanced investigations
- Sputum culture if frequent exacerbations or recent antibiotics
- BNP, D-dimer or CTPA if HF or PE suspected
04Treat
Immediate management
- Controlled oxygen to SpO2 88-92%
- Short-acting beta-agonist with or without ipratropium, by nebuliser or spacer
- NIV if pH under 7.35 and PaCO2 over 45 mmHg despite initial therapy
First-line treatment
- Prednisone 40 mg daily for 5 days
- Antibiotics for increased sputum purulence plus increased dyspnea or sputum volume, or if ventilated: amoxicillin-clavulanate, doxycycline or azithromycin for 5 days
Second-line treatment
- Intubation if NIV fails or is contraindicated
- IV magnesium is sometimes used; evidence is limited
Specialist referrals
- ICU for NIV failure or worsening acidosis
- Pulmonary rehabilitation after recovery
- Smoking cessation service
05Disposition
Admission criteria
- Severe dyspnea, hypoxia or hypercapnia
- Failure of outpatient management
- Serious comorbidity or new arrhythmia
- Insufficient support at home
Safe discharge criteria
- Clinically stable 12-24 h on home regimen
- SABA needed no more than every 4 h
- Ambulating; oxygen needs at baseline
- Inhaler technique checked
Follow-up timing
- Review within 1-4 weeks of discharge
Patient instructions
- Written action plan
- Return if needing reliever more than every 4 h or if drowsy
Monitoring
- Repeat gas 1 h after starting NIV
- SpO2 target 88-92%
Clinical pearls and pitfalls
- Over-oxygenation in CO2 retainers worsens hypercapnia
- Optimize maintenance therapy (LAMA/LABA ± ICS by eosinophils) before discharge
RefGuidelines and landmark evidence
For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.