Acute exacerbation of chronic obstructive pulmonary disease

Last updated: March 8, 2021

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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.”

General principles

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]

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

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


  • 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

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]


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



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]


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

Indications for hospital admission [2]

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


Prior intervention for PVD


Prior intubation for respiratory distress


Pulse ≥ 110/min


Diagnostic test results

Hemoglobin < 10 g/dL


BUN ≥ 34 mg/dL


Serum CO2 ≥ 35 mEq/L


Ischemic changes on ECG


Pulmonary congestion on CXR


Evaluation after initial treatment

SpO2 < 90% or pulse ≥ 120/min


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

Respiratory support

Medical therapy

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