Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
COPD exacerbations are marked by increased dyspnea, cough, and sputum changes, often precipitated by viral/bacterial infection or environmental exposure. Assess for hypercapnic respiratory failure and co‑morbid cardiopulmonary disease; obtain CXR to exclude pneumonia or pneumothorax when indicated.
Treatment Strategy & Disposition
Treat with short‑acting bronchodilators, systemic corticosteroids, and antibiotics when Anthonisen criteria are met or severe disease is present. Provide oxygen targeting 88–92% to avoid CO₂ retention; use NIV for acute hypercapnic failure when appropriate. Optimize maintenance inhalers and arrange pulmonary rehab/smoking cessation. Disposition ranges from outpatient management to ICU depending on gas exchange and clinical trajectory.
Epidemiology / Risk Factors
- Smoking/chronic lung disease; infections or immobility (VTE)
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CXR | Infection/edema/PTX | Consolidation/effusion/PTX | |
| ABG/VBG | Oxygenation/ventilation | Hypoxemia/hypercapnia | |
| CT chest (indicated) | PE/other | Findings vary |
When to Start Antibiotics
| Criteria | Examples |
|---|---|
| Cardinal symptoms | Dyspnea, sputum volume, sputum purulence |
| Ventilatory support | Invasive or noninvasive |
| Severe comorbidity/risk | Frequent exacerbations, bronchiectasis |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Albuterol ± ipratropium | β2-agonist ± antimuscarinic | Minutes | Bronchodilation | Tachycardia, dry mouth |
| Systemic corticosteroid | Glucocorticoid receptor | Hours | Decrease inflammation; shorten recovery | Hyperglycemia |
| Azithromycin or doxycycline | Antibacterial | Hours | If cardinal symptoms or severe | QT prolongation / photosensitivity |
| Noninvasive ventilation | N/A | Immediate | Hypercapnic respiratory failure | Skin breakdown |
Prognosis / Complications
- Depends on severity/oxygenation; respiratory failure risk
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
Notes
Check for pneumonia or heart failure. Avoid excessive oxygen; titrate carefully. Consider magnesium sulfate IV for severe bronchospasm.
References
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