Pulmonology Topic

Acute COPD exacerbation.

AECOPD definition and mimics, oxygen target 88–92% (hyperoxia kills), bronchodilator + 5-day prednisone per REDUCE, antibiotic criteria, NIV indications, and a discharge bundle where the most preventable readmission factor is inhaler technique.

Reviewed June 2026 · verify against current guidelines

Diagnosis & Workup

Recognize. Confirm. Stage.

Definition (GOLD 2026)

Acute worsening of respiratory symptoms (↑ dyspnea, cough, sputum volume or purulence) requiring additional therapy.

Severity (Rome 2026, GOLD-adopted)

Mild	Dyspnea VAS <5 · RR <24 · HR <95 · SpO₂ ≥92% · CRP <10
Moderate	Any of: VAS ≥5, RR ≥24, HR ≥95, SpO₂ <92% or drop >3%, CRP ≥10
Severe	Hypercapnia (PaCO₂ >45) and/or acidosis (pH <7.35)

Rule out mimics

Differential	Pneumonia, acute HF or pulmonary edema, PE, pneumothorax, ACS, arrhythmia.
Workup	CXR, ECG, BNP, troponin. D-dimer if PE risk.

Severe (hypercapnia or acidosis, pH <7.35) = early NIV. Do not wait for fatigue.

VAS visual analog scale (dyspnea)CRP C-reactive proteinNIV non-invasive ventilationACS acute coronary syndrome

Acute Management

First moves. First hours.

Treatment bundle

Oxygen	Target SpO₂ 88-92%. Venturi mask to titrate. Recheck ABG 30-60 min.
Bronchodilators	SABA plus SAMA nebs (albuterol 2.5 mg, ipratropium 0.5 mg) q1–4 h, then q4–6 h.
Steroids	Prednisone 40 mg PO × 5 d (REDUCE). IV methylprednisolone if NPO or severe.
Antibiotics	Per GOLD 2026 criteria below. Duration 5 d.

Antibiotic indications (GOLD 2026, any of)

≥2 cardinal sx	↑ dyspnea, ↑ sputum volume, ↑ purulence. Purulence MUST be one.
Prior + culture	Positive sputum culture during a previous exacerbation.
On ventilation	Mechanical ventilation (invasive or NIV).

Agent choice

First-line	Amox/clav, doxycycline, or macrolide × 5 d.
Pseudomonas risk	Antipseudomonal β-lactam (e.g. pip-tazo, cefepime).

SABA short-acting β-agonistSAMA short-acting muscarinic antagonistABG arterial blood gasNIV non-invasive ventilation

Pitfalls & Disposition

What gets missed.

NIV (when and when not)

Indications	Hypercapnic acidosis (pH <7.35, PaCO₂ >45) · severe dyspnea with WOB · persistent hypoxemia
Contraindications	Respiratory arrest · hemodynamic instability · AMS · vomiting · copious secretions · facial trauma

Intubation triggers

NIV failure · arrest · refractory instability.
Worsening AMS · persistent acidosis · cannot clear secretions.

Discharge bundle

Inhaler technique verified. Watch them use it.
Maintenance escalated if GOLD E (≥1 mod/severe per 2026).
Pulm rehab referral, vaccines, smoking cessation, follow-up <4 weeks.

30-day readmission ~20%. Most preventable factor: inhaler technique.

NIV non-invasive ventilationWOB work of breathingAMS altered mental statusGOLD E GOLD high-exacerbation group

Sources

Verify against current guidelines and local protocol before acting.

GOLD 2026 Global Strategy for Prevention, Diagnosis & Management of COPD.
REDUCE trial (5-day vs 14-day prednisone). JAMA 2013.
Anthonisen et al. Antibiotic use by cardinal symptoms in AECOPD. Ann Intern Med 1987.
Brochard et al. Noninvasive ventilation in acute COPD exacerbation. NEJM 1995.

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High-yield tableCOPD — GOLD ABE classification.

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