Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Controlled oxygen targeting SpO₂ 88–92%; start bronchodilators and steroids.
- Assess for antibiotics criteria; begin NIV in acidotic hypercapnia or severe dyspnea.
- Address triggers (infection, CHF, PE); disposition based on response and risk.
Clinical Synopsis & Reasoning
Worsening dyspnea, cough, and sputum production beyond daily variation. Treat with short‑acting bronchodilators, systemic steroids, and antibiotics when increased sputum purulence/volume or ventilatory support is needed; use noninvasive ventilation for hypercapnic respiratory failure.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Pulse oximetry/ABG | Severity | Hypoxemia/hypercapnia | Targets: SpO₂ 88–92% |
| CXR and viral testing (selected) | Differential | Pneumonia, heart failure, PE | — |
| CBC/BMP and ECG | Complications/precipitants | Infection, arrhythmia, electrolyte disorders | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Severe acidosis (pH <7.25) or hypercapnia | Ventilatory failure | NIV; intubate if NIV fails |
| Hypoxemia refractory to O2 | Life-threatening | Escalate support; ICU |
| Frequent exacerbations or pneumonia | Complicated course | Broaden antibiotics; admit |
| Cardiac ischemia or arrhythmias | Overlap syndromes | Cardiology eval; careful β-agonists |
| Home support unreliable | Safety | Observation/admission |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Albuterol ± Ipratropium nebulizers q4–6 h | Bronchodilators | Minutes | First‑line | — |
| Prednisone 40 mg PO daily ×5 days (or equivalent IV) | Steroid | Hours | Short course effective | Glycemic monitoring |
| Antibiotics (e.g., azithromycin, doxycycline, or amoxicillin/clavulanate) | Antimicrobial | Hours | If purulent sputum or ventilatory support | Local resistance matters |
| Noninvasive ventilation (BiPAP) | Ventilatory support | Immediate | Reduces intubation/mortality in acidotic hypercapnia | Contraindications apply |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- GOLD report on COPD exacerbations — Link