Acute exacerbation of chronic obstructive pulmonary disease

Last updated: August 25, 2023

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Summarytoggle arrow icon

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.

See also “COPD” and “Ventilation strategy for obstructive lung disease.”

Definitiontoggle arrow icon

AECOPD is a clinical diagnosis based on the development of cardinal symptoms of AECOPD (e.g., acute worsening dyspnea, increase in the purulence of sputum) over ≤ 14 days. It is often accompanied by tachypnea, tachycardia, and increased local or systemic inflammation. [2][3]

Etiologytoggle arrow icon

Obtain history of smoking and environmental exposure in all patients with AECOPD. [2]

Clinical featurestoggle arrow icon

Diagnosticstoggle arrow icon

AECOPD is a clinical diagnosis; testing is aimed at assessing severity, identifying triggers, and ruling out complications and/or alternative diagnoses.


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.

AECOPD can be life-threatening. Do not delay treatment for testing in patients who present with respiratory failure or signs of respiratory distress.

Initial studies [2]

Risk stratification [2]

The following tests can help classify AECOPD severity.

Elevated PaCO2 with a normal pH in patients with known COPD is consistent with chronic CO2 retention, while elevated PaCO2 with a low pH suggests acute respiratory failure. [7]

Chest imaging [8]

Microbiological studies [2]

Additional studies [2]

Obtain additional studies based on clinical suspicion.

Pulmonary function testing is not routinely recommended during acute exacerbations. [11]

Most patients with COPD have baseline ECG abnormalities; compare current tracing to prior ECGs to avoid misdiagnosis. [10]

In patients presenting with respiratory exacerbation, consider differential diagnoses of AECOPD (e.g., AHF, pulmonary embolism), especially if there are no signs of infection.

Classificationtoggle arrow icon

See “Classification of stable COPD” for baseline classification.

Classification in primary care settings (Rome proposal) [2][3]

Classification of AECOPD severity in primary care settings
Severity Mild AECOPD Moderate AECOPD Severe AECOPD
Clinical parameters
  • ≥ 3 of the following criteria:
  • Not required
  • If performed, negative for acidemia

Research to validate the thresholds of clinical variables is ongoing. Use clinical judgment when determining the severity of an exacerbation. [3]

Classification in hospitalized patients [2]

Classification of AECOPD severity in hospitalized patients [2]
AECOPD without respiratory failure AECOPD with non-life-threatening acute respiratory failure AECOPD with life-threatening acute respiratory failure
Clinical parameters



  • No worsening from baseline [7]

Differential diagnosestoggle arrow icon

Managementtoggle arrow icon

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.

All patients

Patients with severe AECOPD

Intubation in patients with COPD should be a last resort but should not be delayed in patients presenting with severe respiratory distress or who rapidly decline.

Respiratory supporttoggle arrow icon

Oxygen therapy [2]

Oxygen saturation that is too high poses a risk of oxygen-induced hypercapnia.

Noninvasive positive pressure ventilation (NIPPV) [2]

NIPPV is the preferred ventilation strategy for improving oxygenation and acidosis in AECOPD with acute respiratory failure.

Invasive mechanical ventilation [2]

Intubation and mechanical ventilation are especially high-risk and complication-prone procedures in AECOPD and should only be used as a last resort.

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.

Always check for advanced directives and ascertain the patient's code status (e.g., DNI order) prior to intubation.

Pharmacotherapytoggle arrow icon

Bronchodilators for AECOPD [2][11][12]

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. [2][15]

Glucocorticoids [2][20][21]

Consider glucocorticoids in all patients with AECOPD.

Antibiotics [2][20]

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. [2]

Following clinical stabilization, continue any previously prescribed bronchodilators for COPD maintenance therapy (e.g., long-acting beta-agonists) or start maintenance therapy. [2]

Supportive caretoggle arrow icon

Before stabilization [2]

After stabilization [2]

Following clinical stabilization, continue any previously prescribed long-acting bronchodilators (i.e., LABA and/or LAMA) or consider starting them as indicated for COPD maintenance therapy. [2]

Dispositiontoggle arrow icon

More than 80% of patients with AECOPD are treated as outpatients. [2]

Indications for hospital admission in AECOPD [2]

Indications for ICU admission in AECOPD [2]

Discharge from hospital settings [27]

Clinical decision tools [30]

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

  • 3-minute walk test [31]
    • 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) [28][32]
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

Acute management checklisttoggle arrow icon

Referencestoggle arrow icon

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  3. $Contributor Disclosures - Acute exacerbation of chronic obstructive pulmonary disease. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
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