Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Acute exacerbation of
chronic obstructive
pulmonary disease
Straight to the point of care
Last updated: May 26, 2021

Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Risk factors 4
Aetiology 6
Pathophysiology 7
Case history 8
Diagnosis 9
Recommendations 9
History and exam 23
Investigations 29
Differentials 35
Criteria 39
Management 42
Recommendations 42
Treatment algorithm overview 58
Treatment algorithm 60
Primary prevention 81
Secondary prevention 82
Patient discussions 83
Follow up 84
Monitoring 84
Complications 85
Prognosis 85
Guidelines 86
Diagnostic guidelines 86
Treatment guidelines 86
Online resources 88
Evidence tables 89
References 92
Images 105
Disclaimer 106
Acute exacerbation of chronic obstructive pulmonary
disease Overview
Summary
Acute exacerbation of COPD typically presents with an increased level of dyspnoea, worsening of chronic
cough, and/or an increase in the volume and/or purulence of the sputum produced.
OVERVIEW
May represent the first presentation of COPD, usually associated with a history of tobacco exposure.
Treatment includes bronchodilators, systemic corticosteroids, and antibiotics.
Antibiotics may be reserved for exacerbations thought to be due to bacteria. An acute change in the volume
and colour of sputum produced is suggestive of a bacterial trigger.
Definition
Chronic obstructive pulmonary disease (COPD) is "a common, preventable and treatable disease that is
characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar
abnormalities usually caused by significant exposure to noxious particles or gases and influenced by host
factors including abnormal lung development."[1]
An exacerbation of COPD may be defined as "an acute worsening of respiratory symptoms that results in
additional therapy."[1]
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: May 26, 2021.
BMJ Best Practice topics are regularly updated and the most recent version
3
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2021. All rights reserved.
disease Theory
Epidemiology
COPD is the fourth leading cause of death worldwide, and the third leading cause of death in the United
States.[1] [3] The death rate due to COPD increased over 100% between 1970 and 2002.[4] No other major
THEORY
cause of death in the US has increased at this rate. Globally, COPD has been shown to be responsible for
3.8% of deaths in high-income countries and 4.9% of deaths in low-income countries.[5]
There is significant variability in the prevalence of COPD between countries. [6] [7] [8] This may be due
to differing rates of exposure to tobacco smoke and indoor and occupational pollutants.[5] In the UK, the
prevalence of COPD diagnosed by physicians between 1990 and 1997 was 2% in men and 1% in women.[9]
In the past, men have experienced higher rates of disease due to COPD. This difference has been thought to
be due primarily to greater exposure to tobacco smoke and occupational pollutants. Surveys have shown that
the prevalence of COPD appears to be becoming more equally distributed between men and women.[7] [10]
COPD contributes a significant burden of healthcare costs.[6] Exacerbations are responsible for much of the
morbidity and mortality experienced by people with COPD, and the median number per year ranges between
1 and 3.[11] [12] It has been clearly shown that patients with more severe manifestations of COPD have
greater rates of mortality over time.[6] However, estimates of mortality may be underestimated, as deaths in
this population are often attributed to other aetiologies such as other respiratory disorders, lung cancer, and
cardiovascular disease.[6]
Acute exacerbations of COPD are commonly triggered by bacterial or viral pathogens, pollutants, or
changes in temperature and humidity, and present with an acute-onset, sustained worsening of the patient's
respiratory symptoms, lung function, functional status, and quality of life.[11] [13] [14] [15] [16] [17] [18]
Exacerbation rates and all-cause mortality tend to be higher during winter months.[19] Acute exacerbations
of COPD, particularly those that are moderate to severe, have significant public health impact, with increased
healthcare utilisation and healthcare costs and increased mortality.[20] [21] [22] [23] [24] Early deaths among
patients hospitalised with severe COPD exacerbation are often caused by concurrent problems such as
pulmonary embolus, pneumonia, or congestive heart failure. [25] Patients may also be at risk of myocardial
infarction and stroke in the post-exacerbation period.[26]
Risk factors
Strong
bacterial infection
Bacterial pathogens are thought to be responsible for the majority of acute exacerbations of COPD.
Evidence suggests that the presence of purulent sputum is frequently associated with a bacterial lower
respiratory tract infection.[58] Because the lower respiratory tract in people with COPD is not sterile,
the interpretation of culture results of both upper and lower respiratory tract specimens must be made
with caution. There is mixed evidence as to whether greater bacterial colony counts over baseline
levels are present in patients with an acute exacerbation of COPD.[59] [60]
The most frequently identified bacterial pathogens include Haemophilus influenzae , Streptococcus
pneumoniae , and Moraxella catarrhalis .[31] [51] The role of other gram-positive pathogens such
as Staphylococcus aureus and gram-negative pathogens such as Pseudomonas aeruginosa in the
pathogenesis of acute exacerbations of COPD is less certain, but patients with more severe COPD
and greater frequency and/or severity of exacerbations, or those who have been hospitalised recently
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: May 26, 2021.
disease Theory
or had recent (within 2 weeks) daily use of systemic corticosteroids (i.e., >10 mg/day of prednisolone)
are more likely colonised with these pathogens.[31] [61]
Of note, it has been shown that acquisition of a new strain of bacteria by people with COPD is a risk
THEORY
for an acute exacerbation.[62] Alterations in the innate and/or adaptive immune response may result in
cyclical perpetuation of inflammation and infection.[42]
Concurrent infection with both bacterial and viral respiratory tract pathogens has been associated
with more severe episodes.[50] Treatment of moderate to severe exacerbations with antibiotics has
been associated with improved outcomes.[63] [64] Influenza vaccination may have protective effect in
reducing risk of Pseudomonas aeruginosa infection.[31]
gastro-oesophageal reflux and/or swallowing dysfunction

Gastro-oesophageal reflux and swallowing dysfunction with associated aspiration are common triggers
for exacerbations of COPD.[65] [66] Few studies guide whether the treatment of reflux improves
exacerbations of COPD. In one observational study of more than 600 patients with stable COPD,
treatment with proton pump inhibitors did not decrease the risk for severe exacerbations.[67]
viral infection
It has been estimated that respiratory viruses are responsible for 22% to 50% of acute
exacerbations.[33]
The rhinovirus has been isolated from patients with acute exacerbations of COPD more often than
other viruses.[68]
Influenza, respiratory syncytial virus, parainfluenza, coronavirus, adenovirus, and human

metapneumovirus have also been associated with episodes.[31] [34] [35] [69]
Exacerbations associated with respiratory viruses have been shown to be more severe and take longer
to resolve compared with those attributed to other triggers.[68] [70] Co-infection with viruses and
bacterial pathogens is not uncommon.
It has been hypothesised that the chronic presence of respiratory viruses in the lower respiratory tract
may play a role in the pathogenesis of COPD.[71]
pollutants
Increasing levels of pollutants, specifically nitrogen dioxide (NO 2 ), sulphur dioxide (SO 2 ), ozone (O
3 ), and black smoke particulates, including wood smoke, have been associated with a greater rate of
acute exacerbations and hospital admissions for people with COPD.[72] [73] [74] Peaks of air pollution
can also increase hospitalisations and mortality.[75]
Exposure to many of these pollutants has been found to induce an inflammatory response in the
respiratory tract.[28]
Short-term exposure to fine particulate matter is associated with increased hospitalisations for acute
exacerbations and increased mortality.[1]
Weak
5
disease Theory
atypical bacterial infection
Atypical organisms ( Mycoplasma pneumoniae , Chlamydia pneumoniae , and Legionella species)
have been associated with acute exacerbations though with conflicting results.[76] [77] [78] There is
insufficient evidence to suggest that antimicrobial coverage of atypical bacterial pathogens improves
THEORY
outcomes.
change in weather
Changes in temperature and humidity are associated with increased risk for acute exacerbations of
COPD.[28] [79] However, it remains unclear whether changes in ambient temperature and/or humidity
or changes in risk for infection due to respiratory viruses and/or other pathogens account for this
association.
Exacerbation rates and all-cause mortality tend to be higher during winter months.[19]
Aetiology
The most common cause of COPD in the developed world is exposure to tobacco smoke. Data have
shown that, over time, 50% of chronic smokers develop COPD.[6] [27] The development of COPD is a
complex process that is not completely understood. Inflammation, oxidant-antioxidant imbalance, protease-
antiprotease imbalance, and several additional processes including recurrent infection, immunosenescence,
autoimmunity, altered tissue healing, and other mechanisms are all implicated in the pathogenesis of COPD.
While tobacco smoking is a well-recognised cause of COPD, the risk for developing COPD may also depend
on gender, genetic and socioeconomic factors, as well as exposures to dusts, chemicals, or pollutants, and
early childhood severe respiratory infection. The genetic risk factor that is best documented is a severe
hereditary deficiency of alpha-1 antitrypsin, a major circulating inhibitor of serine proteases.[1]
Acute exacerbations of COPD occur intermittently throughout the course of the disease over the patient’s
lifetime. Exacerbations vary in severity and are thought to be triggered primarily by infections (both viral and
bacterial) and airborne pollutants.[28] In approximately one third of COPD exacerbations, no clear cause can
be identified. A careful search for other causes of respiratory decompensation (e.g., congestive heart failure
or pulmonary embolus) should be considered in such cases.[5] [6]
During an episode, decreases in the FEV 1 , forced vital capacity, and peak expiratory flow may be identified
and are due at least in part to airway inflammation.[11] [28] [29] However, exacerbations are diagnosed by
the identification of typical signs and symptoms rather than by spirometry.[30]
Bacterial pathogens are thought to be responsible for triggering 50% to 70% of exacerbations. The most
common bacterial pathogens include Haemophilus influenzae , Streptococcus pneumoniae , and Moraxella
catarrhalis .[28] [31] Atypical bacterial pathogens such as Mycoplasma and Chlamydia pneumoniae are
also thought to trigger exacerbations, as are respiratory viruses such as rhinovirus, influenza, respiratory
syncytial virus, parainfluenza virus, and human metapneumovirus.[32] [33] [34] [35] The severity of baseline
lung function impairment influences the profile of pathogens most likely to be present.[31]
Exacerbations may also be due to environmental pollutants such as smoke particulate matter, sulphur
dioxide, nitrogen dioxide, and ozone.[36] [37]
disease Theory
Pathophysiology
Smoking, or other significant exposure to smoke, is noted in most people with COPD. Components of smoke
lead to impaired integrity of the tight junctions between lung epithelial cells,[38] stimulate inflammation, and
THEORY
have been shown to decrease respiratory tract mucociliary clearance, increasing the likelihood of microbial
pathogens penetrating the normally sterile lower respiratory tract.[39] [40] [41] The presence of microbial
flora leads to antigen presentation and stimulation of the innate and then the adaptive immune response.[42]
Over time, chronic irritation by smoke and the inflammatory response leads to emphysema, hypertrophy
of airway mucous glands, small airway fibrosis, and a decrease in the elastic recoil of the lung.[43] The
decrease in elastic recoil (due to emphysema) and/or obstruction of the small airways due to inflammation,
oedema, and hypersecretion of mucus leads to decreased FEV 1 and FEV 1 /FVC.[44] Hyperinflation that
results from airflow limitation is a main cause of dyspnoea.[45] Unlike asthma, airflow limitation in COPD is
not fully reversible with medical therapy.[46] Furthermore, while the pathogenesis of both asthma and COPD
is rooted in inflammation, the specific inflammatory process differs between these disorders.[12] However, a
substantial number of patients with COPD do have a component of airflow obstruction that is reversible with
bronchodilator therapy.[47] Indeed, inhaled bronchodilators (beta-2-agonists and anticholinergics) are one of
the primary forms of therapy for all patients with COPD, because, in addition to bronchodilation, they have
also been shown to decrease dynamic hyperinflation.[48] [49]
Acute exacerbations of COPD may be defined as an acute worsening of respiratory symptoms (e.g.,
dyspnoea, cough, sputum production) that results in additional therapy.[1] This worsening appears to
result from increases in airway inflammatory cells and proteins that are triggered by an infection, airborne
pollutants, and/or other factors.[29] [50] [51] [52] The acute on chronic inflammatory response and/or
concurrent bronchoconstriction leads to worsening in expiratory airflow limitation.[14] Worsening of expiratory
airflow limitation leads to increased resistive work of breathing, increased ventilation/perfusion mismatch,
and gas exchange disturbances. It also results in increased hyperinflation, which then further worsens lung
mechanics and can lead to impaired function and fatigue of the respiratory muscles.[14] Due to the difficulty
in obtaining specimens from people with exacerbations of COPD, further complicated by heterogeneous
triggers, knowledge of the inflammatory response during an episode is incomplete.
Acute exacerbations have significant impact on activity level, functional status, and quality of life experienced
by people with COPD.[1] [12] [53] Moreover, recovery from exacerbations may be prolonged, and some
patients never regain their prior level of lung function and/or functional status.[11] There is evidence to
suggest that exacerbations not only tend to be more frequent and more severe as COPD progresses,[54] [55]
but may themselves accelerate the decline in lung function in COPD.[22] Indeed, some patients may also be
at increased risk for COPD exacerbations (i.e., have a phenotype of increased susceptibility) independent
of disease severity.[55] Currently recommended assessment of COPD patients includes determination
of the severity of the airflow obstruction, assessment of symptoms, as well as assessment of the risk of
exacerbations. People with severe or very severe airflow obstruction, those with a history of two or more
exacerbations in the preceding year, or those with history of hospitalisation due to exacerbation in the
previous year are considered at high risk of subsequent exacerbations.[1] Several additional factors are also
associated with exacerbations and/or hospitalisations for COPD.[56] [57] COPD exacerbations, particularly
those requiring hospitalisation, are associated with increased mortality, as well as significant healthcare
costs.[1]
7
disease Theory
Case history
Case history #1
THEORY
A 67-year-old woman with a history of COPD presents with 3 days of worsening dyspnoea and increased
frequency of coughing. Her cough is now productive of green, purulent sputum. The patient has a 100-
pack-year history of smoking. She has had intermittent, low-grade fever of 37.7°C (100°F) for the past
3 days and her appetite is poor. She has required increased use of rescue bronchodilator therapy in
addition to her maintenance medications to control symptoms.
Other presentations
COPD often goes unrecognised. By the time that COPD is diagnosed, patients typically experience
dyspnoea with only mild to moderate exertion and may have a chronic productive cough, and FEV 1 is
often already <50% of predicted level. Many patients are diagnosed with COPD for the first time when
they require hospitalisation for an acute exacerbation of disease.[2] Exacerbations may be triggered by
an infection or exposure to an airborne pollutant or other change in environmental conditions. Patients
commonly present with a complaint of increased dyspnoea, a change in the intensity and frequency
of chronic cough and/or wheezing, and a change in the colour and/or volume of sputum produced.
Patients experiencing an exacerbation may have a low-grade fever, but the presence of a fever, especially
>38.5°C (>101.3°F), should increase suspicion for an alternate diagnosis such as pneumonia.
disease Diagnosis
Recommendations
Urgent
Consider whether COVID-19 infection could be causing acute symptoms. In practice, it may be difficult
to differentiate between COVID-19 infection and an acute exacerbation of COPD clinically. Arrange a
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction
test if a patient with COPD presents with new or worsening respiratory symptoms, fever, and/or any other
symptoms that could be COVID-19 related, even if these are mild. See our topic [Coronavirus disease
2019 (COVID-19).]
Be alert to the presence or imminent onset of acute respiratory failure . Involve your senior team if you
suspect this.
Check for signs of life-threatening complications of COPD or common comorbidities, such as cor
pulmonale, haemodynamic instability, heart failure, and sepsis.
• Investigate and manage with the multidisciplinary team appropriately. Admission to a higher-level
care facility (high-dependency unit or intensive care unit) may be necessary.
Be aware that the patient’s status can change quickly.
Perform an arterial blood gas (ABG) to detect chronic hypercapnia and assess for acute respiratory
acidosis.
• Patients with acute decompensated respiratory failure with acidaemia (pH <7.35 and PaCO₂ >6.5
kPa) have a poor prognosis.
In the community , consider referring the patient to hospital urgently if they have:[1]
• Sudden worsening of resting dyspnoea

• High respiratory rate/acute respiratory failure (>30 breaths/minute)
• Decreased oxygen saturation (SaO₂): SaO₂ <90% on air[88] or deteriorating SaO₂ in patients with
DIAGNOSIS
known hypoxaemia (i.e., those on long-term oxygen therapy)
• Confusion or drowsiness
• Change in or onset of new physical signs, such as cyanosis or worsening peripheral oedema
• Failure to respond to initial management
• Serious comorbidities that would affect recovery or impact treatment, such as heart failure, atrial
fibrillation, or other cardiorespiratory conditions
• Insufficient support at home or in the community treatment setting.
Key Recommendations
Presentation
Patients typically present with dyspnoea, cough, and increased sputum purulence and
volume (the cardinal symptoms of an exacerbation of COPD). [1] [88] #
• Document the current degree of shortness of breath using a score validated for exacerbations.
Define how this has changed from the patient’s baseline and/or the rate of deterioration using
previous results or by asking the patient or family/carers.
• Wheeze may also be present.[1] [88]
9
disease Diagnosis
• Identify any comorbidities and any other focal complaints (e.g., chest pain, palpitations, light-
headedness, or leg swelling).
• Monitor the patient using an early warning score, such as the NEWS2 score .[90]
• Check for signs of hyperinflation.
• Auscultate:
• This may reveal wheeze and/or crackles in the presence of concurrent infection or
pneumonia
• Note that patients or relatives may describe ‘wheeze’, especially on exertion, that is actually
upper airway transmitted noise and not wheeze
• Beware a ‘silent chest’ (decreased breath sounds), which may indicate impending
respiratory failure .
Diagnostic confirmation
Make a clinical diagnosis, dependent on the presence and severity of symptoms and a
medical history of COPD confirmed by previous spirometry results .[91]
• Exclude differential diagnoses that require immediate management, such as acute

myocardial infarction or pneumothorax .
Imaging
Request a chest x-ray (CXR) to check for pneumonic consolidation [88] #and to exclude other
diagnoses, such as pneumothorax, lung cancer, or heart failure.#
• A CXR is also useful to check for the presence of respiratory, cardiac, or skeletal comorbidities.[1]
Risk stratification
Exacerbations are defined by the Global Initiative for Chronic Obstructive Lung Disease
(GOLD) as mild, moderate, or severe. [1] #Severe exacerbations may have associated acute
respiratory failure and should be dealt with in hospital. Mild and moderate exacerbations
may be dealt with in primary care or as an outpatient.#
DIAGNOSIS
• Initial observations and physical examination may be what you base decisions on until further
results are available. Once available, these results together with the history and examination
findings determine your management and escalation strategy for the patient.
• Assess the severity of the exacerbation using a prognostic score, such as DECAF (Dyspnoea,
Eosinopenia, Consolidation, Acidaemia, and atrial Fibrillation) or BAP-65. The score will
indicate which patients are likely to benefit from early intervention, such as non-invasive ventilation.
Care planning
Determine escalation policies and 'ceilings of care'.
• You should:
• Assess the patient’s symptoms compared with their baseline functional status
• Obtain a collateral history urgently
• Plan with senior colleagues what to do if the patient deteriorates, including ‘ceilings of
care’ , and consider DNACPR (‘Do Not Attempt Cardiopulmonary Resuscitation’) for patients
not suitable for escalation to an intensive care unit.[88]
disease Diagnosis
Full Recommendations
Clinical presentation
Patients typically present with an acute worsening of one or more existing cardinal
symptoms over several hours or days (requiring a subsequent change in medication): [1] [88] #
• Dyspnoea
• Cough
• Sputum purulence and volume
• Wheeze
• Chest tightness.
Dyspnoea
A common presenting feature of acute exacerbation of COPD. [1] [88] #
Document the current degree of shortness of breath and exercise tolerance. Use a score
validated for exacerbations or refer back to previous score results taken in the stable
condition, such as the extended Medical Research Council dyspnoea (eMRCD) scale, which
is used in stable COPD to grade the degree of breathlessness according to level of exertion.
[92] #
• Define how this has changed from the patient’s baseline and/or the rate of deterioration, if possible,
using previous results or by asking the patient or family/carers.
• This helps determine the escalation strategy and what level of functionality to aim for upon
discharge.
Practical tip
Patients may describe breathlessness in terms of reduced exercise capacity. For example, they
might report only being able to walk 10 metres for the last couple of days, when they would usually
be able to walk 50 metres before feeling short of breath.
DIAGNOSIS
Cough
The patient might report an increase in frequency or severity of cough; [1] [88] #often
productive.#
• Ask about an increase or change in character compared with the patient’s day-to-day cough.
• Sputum quality may change with exacerbations or superimposed infection.[1] [88]
Sputum purulence and volume

Ask if there is a change to the volume, thickness, or colour of the sputum.
• Investigate for bronchiectasis in patients who repeatedly present with exacerbations with purulent
sputum.[1]
An increase in sputum purulence may indicate the presence of bacteria. [1]
• The presence of green sputum has been found to be 94.4% sensitive and 77% specific for the
yield of a high bacterial load , identifying a distinct subset of patients in whom bacteria are
strongly associated with the exacerbation.[93]
• The most frequently identified bacterial pathogens include Haemophilus influenzae ,
Streptococcus pneumoniae , and Moraxella catarrhalis .[31] [51]
11
disease Diagnosis
• Viral infection may also cause increased sputum production alone or lead to an altered environment
that may promote secondary bacterial infection.[93]
• Co-infection with viruses and bacterial pathogens is not uncommon.
Practical tip
It may be difficult to evaluate sputum production as some patients swallow rather than expectorate
it.[1] This will vary from patient to patient, but be aware of this possibility when asking patients about
changes to volume or thickness. Ideally ask for a sample to assess the colour and thickness
yourself.
Wheeze
Auscultate to check for presence of a wheeze. [1] #Beware a ‘silent chest’ (decreased breath
sounds), which may indicate impending respiratory failure.#
• May present as prolongation of the expiratory phase of breathing on examination.

• Consider cardiac causes for wheeze or the presence of asthma.[94]
Practical tip
Transmitted upper airway noise ‘wheeze’ is common both as a symptom and as a sign. Be aware
that patients or relatives may describe ‘wheeze’, especially on exertion, that is actually upper
airway transmit ted noise and not wheeze . Consider this on auscultation. Likewise wheeze
heard at the end of the bed is often from the upper airway rather than small airways and may not
improve with usual COPD treatment.
Chest tightness
Ask if the patient feels ‘tightness’ in the chest.
• May result from worsened airflow limitation and chest hyperinflation.[14]

• Chest pain is common secondary to coughing and/or increased work of breathing (respiratory
muscle discomfort).
• Consider the possibility of an asthma exacerbation , myocardial infarction , or
DIAGNOSIS
pneumothorax if marked chest tightness or other chest discomfort/pain is present. Involve senior
colleagues for appropriate investigation and management.
Practical tip
Many patients with COPD are elderly and frail, and may have comorbidities with abnormal baseline
parameters. When assessing severity, consider any changes in symptom status relative to the
patient’s baseline level rather than using absolute cut-offs.
Respiratory failure
Beware respiratory failure.
Patients may be peri-arrest due to type 1 (hypoxic) or type 2 (hypercapnic) respiratory failure.
In consultation with your senior team, arrange admission to a higher-level care facility (high-
dependency unit or intensive care unit) if the exacerbation is severe and you detect signs of
acute respiratory failure. Observe for: #
• Tachypnoea[1]
• Accessory muscle use[1]
• Chest retractions
• Paradoxical movements of the abdomen
disease Diagnosis
• Cyanosis
• Confusion[1]
• Drowsiness
• Silent chest.
History
Take a detailed history including:
1. Relevant medical history
• Spirometry-confirmed diagnosis of COPD.[91]

• Ask about previous exacerbations and previous use of non-invasive ventilation
, as patients with a history of two or more exacerbations in the preceding year, or those with
a history of hospitalisation due to exacerbation in the previous year, are considered to be at
high risk of subsequent exacerbations.[24] [55]
• Change in symptoms : did existing symptoms worsen , or are there new symptoms ?
How long have the symptoms been present?
• Consider taking a collateral history.

• Recent infection :[1] [88] ask the patient if they have had increased cough,
breathlessness, or mucopurulent sputum in the last 5 days. Ask if they have had a fever or
noticed changes in sputum.
• Viral infections are the main cause of an exacerbation, with human rhinovirus the most
common causative agent.[1]
• Viral infection may also cause increased sputum production alone or lead to an altered
environment that may promote secondary bacterial infection.[93]
• The most frequently identified bacterial pathogens in exacerbations of COPD include
H influenzae , S pneumoniae , and M catarrhalis .[31] [51]
• Co-infection with viral and bacterial pathogens is not uncommon.
• Consider differential diagnoses , such as acute exacerbation of asthma and heart
failure.
• Ask about gastro-oesophageal reflux and/or swallowing dysfunction, a possible trigger for
DIAGNOSIS
exacerbations of COPD.[65] [66]
Practical tip
When asking a patient about previous exacerbations, bear in mind that they may not
think in terms of ‘exacerbations’ but might instead explain that they received antibiotics
and corticosteroids for a previous ‘chest infection’.
It might help to ask about the constellation of symptoms experienced (increased
cough, breathlessness, and mucopurulent sputum) or to ask specific questions about
previous:
• Hospital visits
• GP visits
• Courses of oral corticosteroids or antibiotics.
• Some patients keep corticosteroids as stand-by medication at home and

therefore will be able to take a course without seeing a healthcare provider.
Symptoms of an exacerbation usually last 7 to 10 days, though may be longer.[1]

2. Risk factors for an exacerbation
13
disease Diagnosis
• Smoking : check if the patient currently smokes and/or they have had significant exposure
to tobacco smoke.[88] [91]
• Exposure to pollution :[88] ask about wood smoke, dust, and other pollutants. This
may include biofuel exposure from cooking over an open fire indoors. Check the patient’s
occupation. It may expose them to pollutants or irritants that would cause an exacerbation.
• Short-term exposure to fine particulate matter is associated with increased hospitalisations
for acute exacerbations and increased mortality.[1]
3. Medication
• Check the patient’s adherence to routine COPD medication .

• Ask about previous use of antibiotics (for COPD exacerbations or for other conditions).
This may have led to resistant bacteria.[95]
• Ask about recent use of oral corticosteroids . This may impact the available duration for
further courses of corticosteroids. Consider the need to wean the dose down gradually at the
time of stepping down medication.
• Check if the patient currently uses supplemental ox ygen .
• Check if there has been any change in the patient’s use of a rescue inhaler .
Physical examination
Physical findings vary according to the severity of the exacerbation. Remember that the
patient’s status can change quickly.
• Use an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach to assess

the patient. In hospital, involve your senior team when needed.
Be alert for the presence or imminent onset of respiratory failure. Observe for:
• Tachypnoea[1]
• Accessory muscle use (which may be accompanied by pursed lip breathing)[1]
• Chest retractions
• Paradoxical movements of the abdomen
• Cyanosis
• Confusion[1]
• Drowsiness [1]
DIAGNOSIS
• Silent chest.
Arrange for admission to a higher-level care facility (high-dependency unit or intensive
care unit) if the exacerbation is severe and if there are signs of acute respiratory failure (in
consultation with your senior team) .
Perform a physical examination of the patient.
• Determine: [88]
• Vital signs (including SaO 2 via pulse oximetry or ABG )[96]
• All measurements of a patient's oxygen level – via pulse oximetry or ABG – should
have the fraction of inspired oxygen (FiO 2 ) or O 2 flow rate documented
• Mental status
• Ability to continue to provide self-care at home.
• In the absence of a spirometry-confirmed diagnosis of COPD (check the patient’s notes), arrange
spirometry if the patient is admitted to hospital for an exacerbation. [91]
disease Diagnosis
• During periods of high prevalence of COVID-19 in the community, spirometry should be
restricted to patients requiring urgent or essential tests for the diagnosis of COPD and/or
to assess lung function status for interventional procedures or surgery.[1] [97] Performing
spirometry and pulmonary function testing may lead to SARS-CoV-2 transmission as a result
of droplet and aerosol formation during the tests, especially with coughing.
• Auscultate , checking for presence of wheeze and/or crackles if concurrent infection or
pneumonia.
• Note pulse rate and rhythm.
• Atrial fibrillation is a common comorbidity and forms part of the DECAF score, a prognostic
score that is used to predict in-hospital mortality.
Use initial observations and physical examination to guide early management decisions until
investigations are under way. As test results become available, use these in conjunction with history and
examination findings to determine management and escalation strategies for the patient.
Comorbidities
Check and monitor for signs of life-threatening complications of an acute exacerbation
of COPD or comorbidities, [1] [88] #such as cor pulmonale, haemodynamic instability, and
sepsis.
• Investigate any sinister symptoms, and manage in line with recommended approaches.
• Involve your senior team; admission to a higher-level care facility (high-dependency
unit or intensive care unit) may be necessary.#
Check for signs of haemodynamic instability , such as:[98]
• Pale, clammy skin

• Peripheral cyanosis
• Diminished urine output.
Check for a decline in mental status , which may indicate respiratory failure [1] #or sepsis :
• Confusion
DIAGNOSIS
• Drowsiness
• Reduced consciousness.
Also check for any findings that may indicate an alternative diagnosis , such as pneumonia,
bronchiectasis, lung cancer, pneumothorax, or heart failure.
Practical tip
Remember that an exacerbation of COPD may co-exist with other conditions, such as new-
onset atrial fibrillation, congestive heart failure, or pneumonia. Conditions with similar presenting
symptoms may need to be excluded or considered as comorbidities.
Evidence: Causes of early death in patients hospitalised with COPD exacerbation
Consider comorbidities and complications of COPD contributing to the mortality risk.
A retrospective study looked at the autopsy results of 43 patients with a hospital

admission diagnosis of COPD exacerbation. All had died within 24 hours of admission to
hospital.
15
disease Diagnosis
• Respiratory failure due to a progression of COPD was the primary cause of death in only six
patients (14%), highlighting the importance of considering comorbidities and complications of
COPD.
• The main (primary) causes of death were reported as:
• Cardiac failure (n = 16; 37.2%)

• Pneumonia (n = 12; 27.9%)
• Pulmonary thromboembolism (PTE) (n = 9; 20.9%).
• The study concludes that there should be a focus on recognising and treating these conditions
at the time of hospital admission.[25]
Cor pulmonale
Cor pulmonale may develop as a result of increased pulmonary artery hypoxaemic
vasoconstriction due to exacerbation-induced hypoxaemia. The resulting increase in
pulmonary vascular resistance and/or pulmonary artery pressure can lead to acute right
heart failure.
If you suspect cor pulmonale, exclude other causes of peripheral oedema and make a
clinical diagnosis based on the presence of: [88]
• Peripheral oedema
• Elevated jugular venous pressure
• Hepatojugular reflux
• Systolic parasternal heave
• Relative hypotension
• Loud pulmonary second heart sound.
These signs may be difficult to define in practice due to the presence of a hyperinflated
chest.
Treat cor pulmonale caused by COPD by managing the COPD exacerbation. [88] #
DIAGNOSIS
• Use diuretics to control oedema.

• Review the patient’s current medications.
• Do not use the following medications to treat cor pulmonale caused by COPD:[88]
• Alpha-blockers
• ACE inhibitors
• Calcium-channel blockers
• Digoxin (unless there is atrial fibrillation).
• Consider assessment for long-term oxygen therapy as an outpatient.
Care planning
Early in your assessment, determine escalation policies and 'ceilings of care' with
colleagues, the patient, and relatives. These are difficult conversations and can be distressing for
patients. However, planning in this way avoids making hasty or ill-thought-out decisions later on.
• Assess the exacerbation symptoms compared with the patient’s baseline functional
status to help determine the escalation strategy.
disease Diagnosis
• Plan with senior colleagues what to do if the patient deteriorates, including ' ceilings of care '
;[88] consider DNACPR for patients not suitable for escalation to an intensive care unit.
• Referral to intensive care (with a view to intubate and ventilate) is appropriate for many
patients but, even if successful, may be associated with ICU-related complications.
• Establish the existence of any advance directives. Some patients may express wishes not to
be referred to higher-level care.
• Consider palliative care for appropriate patients with advanced disease.
Use a planning tool, such as the AMBER care bundle. [The AMBER care bundle] #
Practical tip
The AMBER care bundle is a communication and planning tool used in hospitals in the UK. It
supports a systematic approach for clinical teams to proactively manage the care of hospital
patients who are facing an uncertain recovery and who are at risk of dying despite treatment.
AMBER reflects the need for close attention to:
• A ssessment
• M anagement
• B est practice
• E ngagement
• R ecovery uncertain.
In practice, this means:
1. Talk to the patient and their family to let them know that the healthcare team has concerns about
their condition; establish their preferences and wishes
2. Decide together how the patient will be cared for should their condition get worse
3. Document a medical plan
4. Agree these plans with all members of the clinical team.
Monitor the patient's condition closely and ensure daily follow-up. Record any changes and address
any concerns that they or their family may have. [The AMBER care bundle]
Severity and treatment set ting
DIAGNOSIS
There are no absolute criteria to determine the most appropriate treatment set ting. Consider
the full clinical picture in the context of the patient’s usual state.
• Assess severity to determine where and how to treat the patient.[1] [88]
• Use clinical assessment and the change in symptoms from the patient’s baseline to gauge
the severity of an exacerbation.
• Take into account frailty and comorbidities .
• Consult senior colleagues if you are uncertain of the best treatment setting.
• Not all people with an exacerbation of COPD will require admission to hospital. It is
safe to treat some patients in the community.
• Some patients can manage an exacerbation themselves at home or at a community setting,

with an appropriate management plan.
• Along with the clinical presentation, a good understanding of the patient’s social and
functional history as well as knowledge of the local services and support available will help to
guide your decision on the best treatment setting for the patient.
Both GOLD and National Institute for Health and Care Excellence guidelines stratify
exacerbations into mild, moderate, and severe, based on the management required: [1] [88] #
17
disease Diagnosis
DIAGNOSIS
Assess severity to determine where and how to treat the patient

Created by the BMJ Knowledge Centre based on GOLD and NICE guidelines
Referring to hospital
In the community, consider referring the patient to hospital urgently if they have:

• Decreased oxygen saturations: SaO 2 <90% on air[88] or deteriorating SaO 2 in patients with known
hypoxaemia (i.e., those on long-term oxygen therapy)
• Change in or onset of new physical signs, such as cyanosis or worsening peripheral oedema
disease Diagnosis
Severity assessment in hospital
In hospitalised patients, assess the severity of the exacerbation using a prognostic score,
such as DECAF [99] #or BAP-65.
• The score will indicate which patients are likely to benefit from early intervention, such as non-
invasive ventilation.
Further stratify hospitalised patients based on their clinical signs. [1] #
• No respiratory failure#
• Respiratory rate 20 to 30 breaths/minute

• No use of accessory respiratory muscles
• No change in mental status
• Supplemental oxygen given via Venturi mask up to 28% to 35% inspired oxygen (FiO 2 )
restores oxygen saturations
• Ensure that there is no evidence of hypercapnia before moving to higher

concentrations of oxygen
• Perform ongoing assessment of ABGs
• Document the FiO 2 or O 2 flow rate
• No increase in PaCO 2 .
• Acute respiratory failure – non-life threatening#
• Respiratory rate >30 breaths/minute

• Using accessory respiratory muscles
• No change in mental status
• Hypoxaemia improves when supplemental oxygen at higher concentrations is given via
Venturi mask
• Ensure that there is no evidence of hypercapnia before moving to higher
DIAGNOSIS
• PaCO 2 increased compared with baseline or elevated approximately 6.7 kPa (50-60 mmHg).
• Acute respiratory failure – life threatening

• Using accessory respiratory muscles
• Acute changes in mental status
• Hypoxaemia not improved with supplemental oxygen via Venturi mask or increased FiO 2
• You must ensure that there is no evidence of hypercapnia before moving to higher
• PaCO 2 increased compared with baseline or elevated approximately 8 kPa (>60 mmHg) or
acidosis present.
19
disease Diagnosis
Investigations
ABG (in hospital)#

Perform in patients with a moderate to severe acute exacerbation of COPD, when there is any
evidence of hypercapnia, in all hypoxic patients, in all patients requiring ox ygen, and in all
patients who seem unwell.
• Use to detect chronic hypercapnia and assess for acute respiratory acidosis.
• Ensure you compare results with prior baseline ABG (when available).
• Document the FiO 2 or O 2 flow rate of any supplemental oxygen given (controlled oxygen given via
a Venturi mask).
• Performing the ABG while the patient is on controlled oxygen allows the A-a gradient to be
established.
• PaO 2 <8.0 kPa (approximately 60 mmHg) indicates respiratory failure.
• pH <7.35 and PaCO 2 >6.5 kPa define acute respiratory acidosis.[100]
• Acidaemia implies a severe exacerbation and predicts in-hospital and 30-day mortality.[101]
• Repeat after 30 to 60 minutes of treatment with controlled ox ygen and bronchodilators
to check for a rise in PaCO 2 or a fall in pH.[96]
• If possible, perform a blood gas analysis within 30-60 minutes of starting acute NIV.
• Although the British Thoracic Society (BTS) recommends performing blood gas analysis
within 2 hours of starting acute NIV ,[102] in practice, specialists recommend ideally
waiting only 30-60 minutes to check for changes in PaCO 2 #and pH.
• Arrange review by a specialist healthcare professional with expertise in managing
patients on NIV within 30 minutes if blood gas measurements fail to improve. [102]
• Venous blood gas sampling is not considered a reliable alternative measure. [103]
Practical tip
Some patients with known hypoxaemia (e.g., those on long-term oxygen therapy) may have low
oxygen saturations usually. However, deteriorating SaO 2 is concerning and should warrant an
DIAGNOSIS
urgent assessment.
Pulse oximetry (in hospital and in the community)

In hospital, use pulse oximetry at presentation to measure ox ygen saturations as part of
vital signs. [1] [96] #In the community, use pulse oximetry if there are clinical features of a
severe exacerbation. [88]
• Ensure a good pulse wave is picked up by the device.

• During an exacerbation, oxygen saturation is frequently depressed below the patient's baseline
level.
• Document the FiO 2 or O 2 flow rate if supplemental oxygen is given.
ECG (in hospital and in the community if available)#

Perform an ECG, as cardiovascular disease is common in people with COPD. [104] #
• Consider a myocardial infarction or pneumothorax if chest tightness or other chest

discomfort is present. However, note that chest tightness is also a symptom of COPD due to airflow
limitation and chest hyperinflation.
disease Diagnosis
• Patients with COPD are at higher risk of developing cardiac ischaemia and/or arrhythmias, such as
new-onset atrial fibrillation, that can also lead to dyspnoea.
FBC with platelets (in hospital)#

Perform in patients with moderate to severe exacerbations.
• Screens for abnormalities that may suggest additional medical disorders, such as infection or
anaemia.
Urea, electrolytes, and creatinine (in hospital)

• An abnormal result may suggest additional medical disorders.

• Patients with COPD exacerbations may have decreased oral intake and may become volume
depleted.
CRP (in hospital)

• An abnormal result may suggest presence of infection.
CXR (in hospital)

Request for patients with moderate to severe disease and/or suspected pneumonia.
Can be used to exclude differential or comorbid diagnoses, including pneumothorax,

congestive heart failure, and pleural effusion.
Radiological changes seen in COPD include (but be aware these are not diagnostic of an
exacerbation):
DIAGNOSIS
• Flattened diaphragm and increased retrosternal air space volume, indicating lung hyperinflation
• Hyperlucency of the lungs
• Rapid tapering of vascular markings.[1]
Sputum microscopy, culture, and Gram stain (in hospital)

Obtain for potential bacterial pathogens that may have triggered the episode. Use in severe
disease and if hospitalisation is being considered.
• Not a routine investigation in primary care.

• The most frequently identified bacterial pathogens include H influenzae , S pneumoniae , and M
catarrhalis .[31] [51]
Vitamin D (in hospital or in the community)

Once they are stable, investigate all patients who have required hospitalisation for an exacerbation of
COPD for vitamin D deficiency. Vitamin D levels are lower in patients with COPD. Supplementation of
patients with severe deficiency results in a reduction in exacerbations and hospitalisation. Assess for
severe vitamin D deficiency (<10 ng/mL or <25 nM) and supplement if required.[1]
21
disease Diagnosis
Further investigations sometimes required in hospital
Blood cultures
Request if the patient has pyrexia.
Respiratory virus diagnostics

Consider in severe disease.
• Use to identify any treatable agent.

• Use to identify the need for expanded infection control precautions in hospital.
Cardiac troponin
Assess for an elevation, which would indicate myocardial injury.
• COPD exacerbations can lead to myocardial injury.

• Elevations in troponin may be associated with increased mortality.[105]
Serum theophylline level

Measure on admission for patients who are taking theophylline or aminophylline therapy.
[88] #
Pro-brain natriuretic peptide

Use to exclude heart failure, a key differential of COPD exacerbation.
CT scan of chest
Use to exclude alternative diagnoses if the diagnosis and basis of respiratory
decompensation remains uncertain after routine CXR.
• May identify a pulmonary embolus, pneumonia, pleural effusion, or a malignancy.

DIAGNOSIS
Spirometry
If there is no recorded spirometry result, and the patient is admitted to hospital for an exacerbation,
arrange spirometry to confirm diagnosis of COPD.[91] The presence of a post-bronchodilator FEV 1 /FVC
<0.70 confirms the presence of persistent airflow limitation.
During periods of high prevalence of COVID-19 in the community, spirometry should be restricted to
patients requiring urgent or essential tests for the diagnosis of COPD, and/or to assess lung function
status for interventional procedures or surgery.[1] [97] Performing spirometry and pulmonary function
testing may lead to SARS-CoV-2 transmission as a result of droplet and aerosol formation during the
tests, especially with coughing.
Practical tip
Do not routinely order a chest CT. Only request a chest CT if you suspect malignancy , a
pulmonary embolus , or bronchiectasis , or when considering surgery .[1] [88]
Do not assess the patient using peak flow as an acute investigation. This is not
recommended for assessment of an exacerbation due to the results being of lower quality[106] or
disease Diagnosis
unreliable. In practice, patients are often unable to perform a good-quality forced expiratory
manoeuvre during an acute exacerbation.
Emerging investigations
Procalcitonin
Procalcitonin is being investigated as a biomarker for the diagnosis of bacterial infections.
[107] [108]
• Higher levels of procalcitonin have been detected in severe bacterial infections.[107]

• It may have a function in guiding when to use antibiotics for the treatment of lower respiratory tract
infection; however, this is unclear.
• A Cochrane review of the use of procalcitonin to guide initiation and duration of antibiotic treatment
in people with acute respiratory tract infections found it lowered the risk of mortality, and led to
lower antibiotic consumption and lower risk for antibiotic-related side effects in all patients, including
those with acute exacerbation of COPD.[107] Further research is required to establish its use in
clinical practice.
• In a separate analysis of 1656 patients, 826 were randomly assigned to a group where the decision
on whether to provide antibiotics was based on the results of a procalcitonin assay (830 patients
were given usual care).[108]
• The assay results did not result in less use of antibiotics.
• There was no significant difference between the procalcitonin group and the usual-care
group in antibiotic-days (mean 4.2 and 4.3 days, respectively; difference −0.05 days; 95%
CI −0.6 to +0.5; P = 0.87) or the proportion of patients with adverse outcomes (11.7% [96
patients] and 13.1% [109 patients]; difference −1.5 percentage points; 95% CI, −4.6 to +1.7;
P <0.001 for non-inferiority) within 30 days.[108]
Point-of-care C-reactive protein (CRP)

Point-of-care CRP testing safely reduces antibiotic use in patients with acute exacerbations
of COPD. [109]
• Raised levels of CRP suggest the presence of bacterial infection.
DIAGNOSIS
• In the community, it is difficult to rapidly determine whether an acute exacerbation is due to an
infection, and antibiotics are often prescribed in case there is an underlying bacterial infection.
• A randomised controlled trial of the use of point-of-care CRP testing to guide antibiotic prescribing
for COPD exacerbations found it reduced unnecessary antibiotic use, without compromising safety
or patient outcomes.[109]
History and exam

Key diagnostic factors
dyspnoea (common)
A sustained increase from the baseline level of dyspnoea beyond day-to-day variation is
the key symptom of an exacerbation. [1] [88]
• Document the current degree of shortness of breath and exercise tolerance.
• Use a score validated for exacerbations or refer back to previous score results taken in
the stable condition, such as the extended Medical Research Council dyspnoea (eMRCD)
23
disease Diagnosis
scale, which is used in stable COPD to grade the degree of breathlessness according to
level of exertion.[92]
• Define how this has changed from the patient’s baseline and/or the rate of deterioration, if
possible, using previous results or by asking the patient or family/carers.
• This helps determine the escalation strategy and what level of functionality to aim
for upon discharge.
Practical tip
Patients may describe breathlessness in terms of reduced exercise capacity. For example,
they might report only being able to walk 10 metres for the last couple of days when they would
usually be able to walk 50 metres before feeling short of breath.
cough (common)
The patient might report an increase in frequency or severity of cough; [1] [88] #often
productive.#
• An increase or change in character compared with the patient’s day-to-day cough.

• Sputum quality may change with exacerbations or superimposed infection.[1] [88]
increased sputum purulence and volume (common)

Ask if there is a change to the volume, thickness, or colour of the sputum.
• Investigate for bronchiectasis in patients who repeatedly present with exacerbations with
purulent sputum.[1]
An increase in sputum purulence may indicate the presence of bacteria. [1]
• The presence of green sputum has been found to be 94.4% sensitive and 77% specific for the
yield of a high bacterial load , identifying a distinct subset of patients in whom bacteria are
DIAGNOSIS
strongly associated with the exacerbation.[93]

• The most frequently identified bacterial pathogens include Haemophilus influenzae ,
Streptococcus pneumoniae , and Moraxella catarrhalis .[31] [51]
• Co-infection with viruses and bacterial pathogens is not uncommon.
Practical tip
It may be difficult to evaluate sputum production as some patients swallow rather than
expectorate it.[1] This will vary from patient to patient, but be aware of this possibility when
asking patients about changes to volume or thickness. Ideally ask for a sample to assess the
colour and thickness yourself.
wheeze (common)
Auscultate to check for presence of a wheeze. [1] #Beware a 'silent chest' (decreased breath
sounds), which may indicate impending respiratory failure.#
disease Diagnosis
• May present as prolongation of the expiratory phase of breathing on examination.
• Consider cardiac causes for wheeze or the presence of asthma.[94]
Practical tip
Transmitted upper airway noise 'wheeze' is common both as a symptom and as a sign. Be aware
that patients or relatives may describe 'wheeze', especially on exertion, that is actually upper
airway transmit ted noise and not wheeze . Consider this on auscultation. Likewise wheeze
heard at the end of the bed is often from the upper airway rather than small airways and may not
improve with usual COPD treatment.
chest tightness/chest pain (common)

Ask if the patient feels 'tightness' in the chest.#
• May result from worsened airflow limitation and chest hyperinflation.[14]

• Chest pain is common secondary to coughing and/or increased work of breathing (respiratory
muscle discomfort).
• Consider the possibility of an asthma exacerbation , myocardial infarction , or
pneumothorax if marked chest tightness or other chest discomfort/pain is present. Involve
senior colleagues for appropriate investigation and management.
Practical tip
Many patients with COPD are elderly and frail, and may have comorbidities with abnormal
baseline parameters. When assessing severity, consider any changes in symptom status relative
to the patient’s baseline level rather than using absolute cut-offs.
tachypnoea (common)
Use an Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to assess
the patient. In hospital, involve your senior team when needed.
DIAGNOSIS
• Observe for tachypnoea.
• Be alert for the presence or imminent onset of respiratory failure.
tachycardia (common)
Note pulse rate and rhythm.
• Atrial fibrillation is a common comorbidity and forms part of the DECAF (Dyspnoea,
Eosinopenia, Consolidation, Acidaemia, and atrial Fibrillation) score, a prognostic score that is
used to predict in-hospital mortality.[99]
risk factors (common)

Take a history covering the likely risk factors for an exacerbation of COPD, including:
Spirometry-confirmed diagnosis of COPD#

Ask about previous exacerbations and previous use of non-invasive ventilation, as
patients with a history of two or more exacerbations in the preceding year, or those with a
25
disease Diagnosis
history of hospitalisation due to exacerbation in the previous year, are considered to be at
high risk of subsequent exacerbations. [24] [55]
• Review the patient’s notes to check for recent spirometry results confirming a diagnosis of
COPD.[91] #If there is no recorded spirometry result, and the patient is admitted to hospital for
an exacerbation, arrange spirometry to confirm diagnosis of COPD.[91] During periods of high
prevalence of COVID-19 in the community, spirometry should be restricted to patients requiring
urgent or essential tests for the diagnosis of COPD and/or to assess lung function status for
interventional procedures or surgery.[1] [97]
• Ask about a change in symptoms : did existing symptoms worsen , or are there new
symptoms ? How long have the symptoms been present?
Recent infection [1] [88]

Ask the patient if they have had increased cough, breathlessness, or mucopurulent
sputum in the last 5 days. Ask if they have had a fever or noticed changes in sputum.
• Viral infections are the main cause of an exacerbation, with human rhinovirus the most common
causative agent.[1]
• The most frequently identified bacterial pathogens in exacerbations of COPD include
Haemophilus influenzae , Streptococcus pneumoniae , and Moraxella catarrhalis .[31] [51]
• Co-infection with viral and bacterial pathogens is not uncommon.
Practical tip
When asking a patient about previous exacerbations, bear in mind that they may not think
in terms of 'exacerbations', but might instead explain that they received antibiotics and
corticosteroids for a previous 'chest infection'.
It might help to ask about the constellation of symptoms experienced (increased cough,
DIAGNOSIS
breathlessness, and mucopurulent sputum) or to ask specific questions about previous:

• Hospital visits
• GP visits
• Courses of oral corticosteroids or antibiotics.
• Some patients keep corticosteroids as stand-by medication at home and therefore will
be able to take a course without seeing a healthcare provider.
Symptoms of an exacerbation usually last 7 to 10 days, though may be longer.[1]
Smoking
Check if the patient currently smokes and/or they have had significant exposure to
tobacco smoke. [88] #
Exposure to pollution [88]

Ask about wood smoke, dust, and other pollutants.
• This may include biofuel exposure from cooking over an open fire indoors.
disease Diagnosis
• Check the patient’s occupation. It may expose them to pollutants or irritants that would cause an
exacerbation.
• Short-term exposure to fine particulate matter is associated with increased hospitalisations for
acute exacerbations and increased mortality.[1]
cor pulmonale (common)

Cor pulmonale may develop as a result of increased pulmonary artery hypoxaemic
vasoconstriction due to exacerbation-induced hypoxaemia. The resulting increase in
pulmonary vascular resistance and/or pulmonary artery pressure can lead to acute right
heart failure.
If you suspect cor pulmonale, exclude other causes of peripheral oedema and make a
clinical diagnosis based on the presence of: [88]
• Peripheral oedema
• Elevated jugular venous pressure
• Hepatojugular reflux
• Systolic parasternal heave
• Relative hypotension
• Loud pulmonary second heart sound.
These signs may be difficult to define in practice due to the presence of a hyperinflated
chest.
Other diagnostic factors

signs of respiratory failure (uncommon)
Assess for signs suggestive of respiratory failure. In consultation with your senior team,
arrange admission to a higher-level care facility (high-dependency unit or intensive care
unit) if the exacerbation is severe and you detect signs of acute respiratory failure.#
DIAGNOSIS
Change in mental status [1]#
Look for drowsiness, confusion, personality change, irritability.
Morning headaches
Sign of worsening hypercapnic ventilatory failure.
• This may be accompanied by increased daytime somnolence.
Malaise and fatigue

These symptoms and other non-specific symptoms such as insomnia, decreased activity
level, and loss of appetite are commonly identified in people with an acute exacerbation
of COPD. [110] [111] #
• These symptoms have a great impact on quality of life, but are not on their own diagnostic of an
exacerbation.
27
disease Diagnosis
Accessory muscle use
Sign of impending respiratory failure.
• This may be accompanied by pursed lip breathing.
Paradoxical movements of abdomen

Sign of impending respiratory failure.
• More common when there is respiratory muscle weakness.
fever (uncommon)
May be a sign of bacterial infection meaning antibiotic therapy is required.
• Consider a bacterial pneumonia or influenza virus infection if there is a high and/or persistent
fever.
gastro-oesophageal reflux and/or swallowing dysfunction (uncommon)

A possible trigger for exacerbations of COPD. [65] [66] #
• No available studies guide whether the treatment of reflux improves exacerbations of COPD.
DIAGNOSIS
disease Diagnosis
Investigations
1st test to order
Test Result
arterial blood gas (in hospital) • PaO 2 <8.0 kPa
Perform in patients with a moderate to severe acute (approximately 60
exacerbation of COPD, when there is any evidence of mmHg) indicates
hypercapnia, in all hypoxic patients, in all patients requiring respiratory failure
ox ygen, and in all patients who seem unwell. • pH <7.35 and PaCO
2 >6.5 kPa define
• Use to detect chronic hypercapnia and assess for acute acute respiratory
acidosis[100]
respiratory acidosis.
• Ensure you compare results with prior baseline ABG
(when available).
• Document the fraction of inspired oxygen (FiO 2 ) or O 2 flow
rate of any supplemental oxygen given (controlled oxygen
given via a Venturi mask).
• Performing the ABG while the patient is on controlled

oxygen allows the A-a gradient to be established.
• PaO 2 <8.0 kPa (approximately 60 mmHg) indicates
respiratory failure .
• pH <7.35 and PaCO 2 >6.5 kPa define acute respiratory
acidosis.[100]
• Acidaemia implies a severe exacerbation and predicts

in-hospital and 30-day mortality.[101]
• Repeat#the ABG after 30 to 60 minutes of treatment with
controlled ox ygen and bronchodilators to check for a rise
in PaCO 2 or a fall in pH.[96]
DIAGNOSIS
• If possible, perform a blood gas analysis within 30-60 minutes
of starting acute NIV.
• Although the British Thoracic Society (BTS)

recommends performing a blood gas analysis within
2 hours of starting acute NIV, [102] in practice,
specialists recommend ideally waiting only 30-60
minutes to check for changes in PaCO 2 and pH.
• Arrange review by a specialist healthcare professional
with expertise in managing patients on NIV within
30 minutes if blood gas measurements fail to
improve .[102]
• Venous blood gas sampling is not considered a reliable
alternative measure. [103]
Practical tip
Some patients with known hypoxaemia (e.g., those on long-

term oxygen therapy) may have low oxygen saturations usually.
However, deteriorating oxygen saturation is concerning and
should warrant an urgent assessment.
29
disease Diagnosis
Test Result
pulse oximetry (in hospital and in the community) • low oxygen saturation,
In hospital, use pulse oximetry at presentation to measure depressed below the
ox ygen saturations as part of vital signs. [1] [96] #In the
patient’s baseline level
community, use pulse oximetry if there are clinical features
of a severe exacerbation. [88]
• Ensure a good pulse wave is picked up by the device.

• During an exacerbation, oxygen saturation is frequently
depressed below the patient's baseline level.
• Document the fraction of inspired oxygen (FiO₂) or O₂ flow rate
if supplemental oxygen is given.
ECG (in hospital and in the community if available) • may be right heart
Perform an ECG as cardiovascular disease is common in enlargement,
people with COPD. [104] #
arrhythmia, ischaemia
• Consider a myocardial infarction or pneumothorax if
chest tightness or other chest discomfort is present. However,
note that chest tightness is also a symptom of COPD due to
airflow limitation and chest hyperinflation.
• Patients with COPD are at higher risk of developing cardiac
ischaemia and/or arrhythmias, such as new-onset atrial
fibrillation, that can also lead to dyspnoea.
FBC with platelets (in hospital) • may show elevated

Perform in patients with moderate to severe exacerbations. haematocrit, elevated
WBC count, or
• Screens for abnormalities that may suggest additional medical
anaemia
disorders, such as infection or anaemia.
DIAGNOSIS
urea, electrolytes, and creatinine (in hospital) • usually normal

• An abnormal result may suggest additional medical disorders.

• Patients with COPD exacerbations may have decreased oral
intake and may become volume depleted.
CRP (in hospital) • elevated CRP suggests

Perform in patients with moderate to severe exacerbations. presence of infection
• An abnormal result may suggest presence of infection.
CXR (in hospital) • hyperinflation, flattened

Request for patients with moderate to severe disease and/or diaphragm, increased
suspected pneumonia.
retrosternal air space
Can be used to exclude differential or comorbid diagnoses, (seen on lateral x-ray, if
including pneumothorax, congestive heart failure, and performed), bullae, and
pleural effusion.
a small vertical heart
suggest COPD, but are
disease Diagnosis
Test Result
Radiological changes seen in COPD include (but be aware not diagnostic for an
these are not diagnostic of an exacerbation): exacerbation
• Flattened diaphragm and increased retrosternal air space

volume, indicating lung hyperinflation
• Hyperlucency of the lungs
• Rapid tapering of vascular markings.[1]
sputum microscopy, culture, and Gram stain (in hospital) • may suggest bacterial
Obtain for potential bacterial pathogens that may have infection
triggered the episode. Use in severe disease and if
hospitalisation is being considered.
• Not a routine investigation in primary care.

• The most frequently identified bacterial pathogens include
Haemophilus influenzae , Streptococcus pneumoniae , and
Moraxella catarrhalis .[31] [51]
vitamin D (in hospital or in the community) • <10 ng/mL or <25

Once they are stable, investigate all patients who have required nM indicates severe
hospitalisation for an exacerbation of COPD for vitamin D deficiency.
deficiency
Vitamin D levels are lower in patients with COPD. Supplementation of
patients with severe deficiency results in a reduction in exacerbations
and hospitalisation. Assess for severe vitamin D deficiency (<10 ng/
mL or <25 nM) and supplement if required.[1]
DIAGNOSIS
31
disease Diagnosis
Other tests to consider
Test Result
blood cultures • may indicate sepsis
Request if the patient has pyrexia.
respiratory virus diagnostics • may confirm viral
Consider in severe disease. infection
• Use to identify any treatable agent.

• Use to identify the need for expanded infection control
precautions in hospital.
cardiac troponin • normal if no myocardial

Assess for an elevation, which would indicate myocardial injury
injury.
• COPD exacerbations can lead to myocardial injury.

• Elevations in troponin may be associated with increased
mortality.[105]
serum theophylline level • therapeutic range:

Measure on admission for patients who are taking 10-20 mg/L (55–110
theophylline (or aminophylline). [88]
micromols/litre)
pro-brain natriuretic peptide (BNP) • normal BNP <100

Use to exclude heart failure, a possible differential of COPD picograms/mL but
exacerbation.
some variability
according to gender
and age
DIAGNOSIS
CT scan of chest • may still show

Use to exclude alternative diagnoses if the diagnosis and presence of
basis of respiratory decompensation remains uncertain after
emphysema, even if
routine CXR.
no pneumonia, pleural
• May identify a pulmonary embolus, pneumonia, pleural effusion, malignancy,
effusion, or a malignancy. or pulmonary embolus
present
Practical tip
D o not routinely order a chest CT. Only request a chest

CT if you suspect malignancy , a pulmonary embolus , or
bronchiectasis , or when considering surgery .[1] [88]
spirometry • confirms diagnosis of
Arrange for all patients admit ted to hospital with an acute COPD
exacerbation if previous spirometry results are not available
to confirm the diagnosis of COPD. [91]
During periods of high prevalence of COVID-19 in the community,

spirometry should be restricted to patients requiring urgent or
disease Diagnosis
Test Result
essential tests for the diagnosis of COPD and/or to assess lung
function status for interventional procedures or surgery.[1] [97]
Practical tip
Do not assess the patient using peak flow as an acute

investigation. This is not recommended for assessment of an
exacerbation due to the results being of lower quality[106] or
unreliable. In practice, patients are often unable to perform
a good-quality forced expiratory manoeuvre during an acute
exacerbation.
Emerging tests
Test Result
procalcitonin • higher levels of
Procalcitonin is being investigated as a biomarker for the procalcitonin have been
diagnosis of bacterial infections. [107] #[108] detected in severe
bacterial infections[107]
• Higher levels of procalcitonin have been detected in severe
bacterial infections.[107]
• It may have a function in guiding when to use antibiotics for the
treatment of lower respiratory tract infection; however, this is
unclear.
• A Cochrane review of the use of procalcitonin to guide initiation
and duration of antibiotic treatment in people with acute
respiratory tract infections found it lowered the risk of mortality,
and led to lower antibiotic consumption and lower risk for
antibiotic-related side effects in all patients, including those
with acute exacerbation of COPD.[107] Further research is
required to establish its use in clinical practice. In a separate
analysis of 1656 patients, 826 were randomly assigned to a
DIAGNOSIS
group where the decision on whether to provide antibiotics was
based on the results of a procalcitonin assay (830 patients
were given usual care).[108]
• The assay results did not result in less use of antibiotics.
• There was no significant difference between the

procalcitonin group and the usual-care group in
antibiotic-days (mean 4.2 and 4.3 days, respectively;
difference −0.05 day; 95% CI −0.6 to +0.5; P = 0.87) or
the proportion of patients with adverse outcomes (11.7%
[96 patients] and 13.1% [109 patients]; difference −1.5
percentage points; 95% CI, −4.6 to +1.7; P <0.001 for
non-inferiority) within 30 days.[108]
point-of-care CRP • elevated CRP suggests

Point-of-care CRP testing safely reduces antibiotic use in patients presence of infection
with acute exacerbations of COPD.[109]
• Raised levels of CRP suggest the presence of bacterial

infection.
33
disease Diagnosis
Test Result
• In the community, it is difficult to rapidly determine whether
an acute exacerbation is due to an infection, and antibiotics
are often prescribed in case there is an underlying bacterial
infection.
• A a randomised controlled trial of the use of point-of-
care CRP testing to guide antibiotic prescribing for COPD
exacerbations found it reduced unnecessary antibiotic use,
without compromising safety or patient outcomes.[109]
DIAGNOSIS
disease Diagnosis
Differentials
Condition Differentiating signs / Differentiating tests

symptoms
Coronavirus disease 2019 • Residence in/travel to a • Real-time reverse
(COVID-19) country/area or territory transcription polymerase
with local transmission, chain reaction: positive for
or close contact with a severe acute respiratory
confirmed or probable case syndrome coronavirus 2
of COVID-19, in the 14 days (SARS-CoV-2) RNA.
prior to symptom onset.
• Signs and symptoms are
similar so it may be difficult
to differentiate between
the conditions clinically.
Maintain a high index of
suspicion for COVID-19 in
patients with COPD who
present with symptoms
of an exacerbation,
especially if accompanied
by fever, impaired taste or
smell, or gastrointestinal
complaints.[1]
• The situation is evolving
rapidly; see our COVID-19
topic for further information.
Acute exacerbation of • An increase in cough may • Extent of asthma

asthma be the first symptom of an exacerbation can be
asthma exacerbation. Ask determined by measuring
about the presence of chest peak flow as a percentage
tightness. of normal value: mild >80%;
• Progressive worsening of moderate 60% to 80%;
DIAGNOSIS
wheeze and shortness of severe <60%.
breath may occur. Assess • Oxygen saturation values
for accessory muscle measured by pulse oximetry
use, tachypnoea, and vary with degree of
tachycardia. exacerbation: mild >95%;
• Key risk factors include: moderate 91% to 95%;
viral infection, exposure to severe <90%.
cigarette smoke, exposure • Treatment with a short-
to allergens, atopic eczema, acting bronchodilator can
environmental irritants, poor also be used as a diagnostic
indoor air quality, gastro- trial. Lack of response is
oesophageal reflux disease, extremely unusual and
history of asthma, use of suggests that the condition is
oral corticosteroids, non- not caused by asthma.
compliance to asthma
medication.
Congestive heart failure • Patients with systolic left- • Chest imaging may show an
sided or biventricular enlarged heart, pulmonary
congestive heart failure will vascular congestion, and/
often have a history of heart or pleural effusions. An
failure. Underlying diastolic elevated B-type natriuretic
35
disease Diagnosis
symptoms
heart failure is often under- peptide is often present.[113]
recognised. [114] An echocardiogram
• Physical examination may may be used to determine
note signs consistent with cardiac function.
heart failure, such as an
elevated jugular venous
pressure, extra heart
sounds, coarse breath
sounds with crackles above
the lung bases, wheezing,
and dependent pitting
oedema.[112] It may be
difficult to distinguish heart
failure, particularly left-sided
heart failure, from an acute
exacerbation of COPD.
Pneumonia • Many aspects of acute • Chest imaging in patients

exacerbations including with pneumonia should
dyspnoea, cough, and identify changes consistent
sputum production may with an infiltrative process in
be found in patients with the lung parenchyma.
pneumonia and it is often
not possible to differentiate
without chest imaging.
• About 10% to 15% of
patients presenting
with an apparent acute
exacerbation are found to
have pneumonia, or other
abnormalities, defined
by chest imaging.[115]
[116] [117] Patients with
DIAGNOSIS
pneumonia have in general

been found to experience
higher fevers, more acute
onset of illness, and
somewhat greater severity of
acute illness when compared
with COPD patients without
pneumonia.[115] [118] The
presence of pneumonia
as a cause of respiratory
decompensation in a
patient with COPD does
not necessarily imply
the presence of a COPD
exacerbation per se (i.e.,
the presence of worsened
airflow limitation related to
airways inflammation and/
or bronchoconstriction),
and as such careful
consideration should be
given as to whether systemic
disease Diagnosis
symptoms
corticosteroids are warranted
in such patients.
Pleural effusion • Pleural effusions may • Chest imaging is

exacerbate dyspnoea recommended.
in patients with COPD.
Physical examination may
demonstrate decreased
or absent breath sounds
with dullness to percussion
related to a pleural effusion.
Pneumothorax • Patients with COPD found • Chest imaging is

to have pneumothoraces recommended to exclude a
may or may not have possible pneumothorax in
additional signs or symptoms patients with more than mild
suggestive of a respiratory episodes.[119]
tract infection, but their
presentation may closely
mirror that of an acute
exacerbation. Decreased
breath sounds may be
identified on the affected
side and tracheal deviation
away from the affected side
and/or hypotension may be
present in patients with a
tension pneumothorax.
Pulmonary embolism • Clinically, pulmonary • Pulmonary embolus may be

embolism may present with diagnosed using D-dimer
signs and symptoms similar assay, spiral computed
to an acute exacerbation tomography angiogram, or
of COPD, and the two are pulmonary angiography in
DIAGNOSIS
difficult to distinguish.[120] patients with COPD. Test
Pulmonary embolism should selection should be based
be considered as a cause on local expertise. Dopplers
of the acute symptoms if of the lower extremities may
no other identifiable trigger be considered to evaluate for
for the exacerbation is deep vein thrombosis.
evident. People with prior
thrombo-embolic disease or
underlying malignancy may
be at particular risk.[120]
• A low systolic blood pressure
and/or the inability to
increase the PaO 2 >60
mmHg with oxygen may
indicate the presence of a
pulmonary embolism.
Cardiac ischaemia • Clinically, may be difficult • An electrocardiogram should

to distinguish. Chest pain be performed, especially for
may be more apparent, with patients who may require
radiation down left side. hospitalisation for care of
an acute exacerbation of
37
disease Diagnosis
symptoms
Nausea, jaw pain, and/or COPD, to identify possible
diaphoresis may be present. cardiac ischaemia and
arrhythmias.[1]
Cardiac arrhythmia • Differentiating features • An electrocardiogram should

may include palpitations, be performed, especially for
light-headedness, loss patients who may require
of consciousness, and/or hospitalisation for care
collapse. of an acute exacerbation
of COPD or who are
experiencing palpitations
or dizziness, to identify
possible cardiac ischaemia
and arrhythmias.[1]
Upper airway obstruction • Large airway obstruction • Spirometry with flow

typically presents with volume loop can identify
dyspnoea and wheeze the presence of upper
(particularly during exertion airway obstruction; when
and with forced exhalation tracheobronchomalacia is
manoeuvre), and it is suspected, CT scanning
commonly mistaken for with inspiration and
refractory exacerbations of expiration views or direct
COPD; variable intrathoracic bronchoscopic airway
upper airway obstruction inspection can be diagnostic.
is often caused by
tracheobronchomalacia, an
aspirated object, or central
airway tumour; variable
extrathoracic upper airway
obstruction is commonly
caused by vocal cord
paralysis, as well as by
DIAGNOSIS
inflammation and swelling

of the perilaryngeal soft
tissues and intermittent
vocal cord spasm associated
with GORD, undiagnosed
or untreated obstructive
sleep apnoea, and chronic
post nasal drip; fixed upper
airway obstruction may be
caused by tracheal stenosis
(e.g., due to prior intubation
for mechanical ventilation),
extrinsic compression
of central airways (e.g.,
lymphadenopathy or
mass), or large airway
tumour; auscultation over
the larynx, trachea, and
main bronchi during both
quiet breathing and forced
exhalation or hyperpnoea
manoeuvre should be done
to evaluate for the presence
disease Diagnosis
symptoms
of upper airway obstruction;
complete resolution of
wheezing during resting
quiet breathing that is
present during exertion
or a forced exhalation
manoeuvre argues
against the presence of
bronchoconstriction related
to COPD exacerbation.
Inappropriate ox ygen • While oxygen therapy • An ABG should be

therapy is clearly indicated for performed for patients
many patients with COPD who are hypoxaemic or
and acute exacerbations, are receiving oxygen
excessive oxygen leads therapy who present with an
to further degradation of apparent acute exacerbation
the patient's respiratory of COPD.
physiology. Exposure to
oxygen leads to decrease
of hypoxic vasoconstriction
of arteries supplying poorly
ventilated spaces, increasing
the degree of V/Q mismatch
and/or intrapulmonary
shunt.[121] [122] An excess
of oxygen may also decrease
the capacity of erythrocytes
to carry CO 2 (Haldane
effect).[123] These changes
may then result in worsening
of the patient's hypercarbia
and respiratory acidosis.
DIAGNOSIS
Selected patients with
impaired respiratory drive
may also develop worsening
hypercarbia.
Criteria
Both GOLD and NICE guidelines stratify exacerbations into mild, moderate, and severe, based
on the management required: [1] [88] #
39
disease Diagnosis
DIAGNOSIS
Assess severity to determine where and how to treat the patient

In hospitalised patients, assess the severity of the exacerbation using a prognostic score, such
as DECAF (Dyspnoea, Eosinopenia, Consolidation, Acidaemia, and atrial Fibrillation) [99] #or
BAP-65.
• The score will indicate which patients are likely to benefit from early intervention, such as non-invasive
ventilation.
Further stratify hospitalised patients based on their clinical signs. [1]
• No respiratory failure#
• Respiratory rate 20 to 30 breaths/minute.

• No use of accessory respiratory muscles.
• No change in mental status.
• Supplemental oxygen given via Venturi mask up to 28% to 35% inspired oxygen (FiO 2 ) restores
oxygen saturations.
disease Diagnosis
• Ensure that there is no evidence of hypercapnia before moving to higher concentrations
of oxygen.
• Perform ongoing assessment of arterial blood gas (ABG).
• Document the FiO 2 or O 2 flow rate.
• No increase in PaCO 2 .
• Acute respiratory failure – non-life threatening
• Respiratory rate >30 breaths/minute.

• Using accessory respiratory muscles.
• No change in mental status.
• Hypoxaemia improves when supplemental oxygen at higher concentrations is given via Venturi
mask.
concentrations of oxygen.
• Perform ongoing assessment of ABGs.
• PaCO 2 increased compared with baseline or elevated approximately 6.7 kPa (50-60 mmHg).
• Acute respiratory failure – life threatening#
• Respiratory rate >30 breaths/minute.

• Using accessory respiratory muscles.
• Acute changes in mental status.
• Hypoxaemia not improved with supplemental oxygen via Venturi mask or increased FiO 2 .
concentrations of oxygen.
• Perform ongoing assessment of ABGs.
• PaCO 2 increased compared with baseline or elevated approximately 8 kPa (>60 mmHg) or
DIAGNOSIS
acidosis present.
41
disease Management
Recommendations
Urgent
If COVID-19 infection is confirmed, manage the patient in line with your local COVID-19 guidelines. See
our topic [Coronavirus disease 2019 (COVID-19).]
• Use systemic corticosteroids in COPD exacerbations according to the usual indications (see Initial
pharmacological management below) whether or not there is evidence of severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) infection. There is no evidence that this approach modifies
the patient’s susceptibility to SARS-CoV-2 infection or worsens outcomes.[1]
• Treat the patient with antibiotics according to the usual indications (see Treat the underlying cause
below) whether or not there is evidence of SARS-COV-2 infection, particularly as patients with
COPD who also have COVID-19 frequently develop bacterial or fungal co-infections.[1]
Immediately give a short-acting beta-2 agonist (at an increased dose or frequency from the patient’s
usual baseline treatment), with or without a short-acting muscarinic antagonist. [1]
• Stop any long-acting muscarinic antagonist the patient may already be on for maintenance therapy
if a short-acting muscarinic antagonist is given.
Consider a systemic corticosteroid. [1] [88]
Prescribe controlled ox ygen for severe exacerbations in patients who are hypoxic.
• Titrate controlled ox ygen to a target saturation of 88% to 92% as COPD patients are
considered at risk of hypercapnic (type 2) respiratory failure.[1] [96]
Obtain arterial blood gas (ABG) and pulse oximetry measurements on presentation and repeat after 30
to 60 minutes. [1] [96]
Monitor for signs of hypercapnic (type 2) respiratory failure with respiratory acidosis.
Acute respiratory failure is life-threatening when:[1]

• Patient using accessory respiratory muscles
• Acute changes in mental status
• Hypoxaemia does not improve with supplemental oxygen via Venturi mask or requiring fraction of
inspired oxygen (FiO₂) >40%
• Ensure that there is no evidence of hypercapnia before moving to higher concentrations of

oxygen.
• Carry out ongoing assessment with ABGs.
• Document the FiO₂ or O₂ flow rate.
MANAGEMENT
• PaCO₂ increased compared with baseline or elevated approximately 8 kPa (>60 mmHg), or
acidosis present.
In the community , refer the patient to hospital if they have:[1]
disease Management
• Decreased oxygen saturation (SaO₂): SaO₂ <90% on air,[88] or deteriorating SaO₂ in patients with
known hypoxaemia (i.e., those on long-term oxygen therapy)
• Acute respiratory failure
• Change in or onset of new physical signs, such as cyanosis or worsening peripheral oedema[88]
Key Recommendations
Initial treatment for all patients
Give a short-acting beta-2 agonist (with or without a short-acting muscarinic antagonist)
and consider a systemic corticosteroid .[1]
• For the beta-2 agonist, use:
• A nebuliser driven on air (not ox ygen, due to the risk of hypercapnia) for a
moderate to severe exacerbation[88]
• During the COVID-19 pandemic, seek advice from a respiratory specialist and
consult local guidelines before using a nebuliser. There are currently differences
of opinion between organisations in different countries on whether use of a nebuliser is
an aerosol-generating procedure
• A metered-dose inhaler (MDI) plus spacer for a mild exacerbation.
• Add a short-acting muscarinic antagonist (e.g., ipratropium) administered via a
nebuliser if the initial dose of the short-acting beta-2 agonist does not provide
sufficient and prompt benefit. [1] [124]
• Stop any long-acting muscarinic antagonist the patient may already be on for maintenance
therapy if a short-acting muscarinic antagonist is given.
Monitor the patien t using an early warning score, such as the NEWS2 score :[90]
• Respiration rate
• Oxygen saturation (document FiO₂ or O₂ flow rate)
• Systolic blood pressure
• Pulse rate
• Level of consciousness or new-onset confusion
• Temperature.
MANAGEMENT
Ox ygen
Titrate controlled ox ygen to a target saturation of 88% to 92%, as COPD patients are
considered at risk for hypercapnic (type 2) respiratory failure. [1] [96] [100]
43
disease Management
• Use a Venturi mask to deliver 24% to 28% oxygen.[96]
• Document the FiO₂ or O₂ flow rate .
• Check blood gases to ensure satisfactory oxygenation and monitor for carbon dioxide retention
and acidosis.
• Obtain arterial blood gas and pulse oximetry measurements on admission and then
after 30 to 60 minutes.[1] [96]
• Repeat ABG if the patient's clinical condition deteriorates or they fail to respond to initial
therapy.
Avoid excessive ox ygen use in patients with COPD as this can lead to worsening
hypercapnia, acidosis, and respiratory failure and death .
• This can develop rapidly (within the time of a hospital admission) even if the initial blood gas results
were satisfactory.[96]
• Beware that hypercapnic respiratory failure and death may occur as a consequence of high oxygen
delivery in an ambulance when attempting hypoxaemia correction.[125]
Ventilation
Start non-invasive ventilation (NIV) for patients who have any of the following, despite
optimal medical therapy, [100] #and have no contraindications to treatment :[1]
• R espiratory acidosis (pH <7.35 and PaCO₂ >6.5 kPa).[100]
• S evere dyspnoea (as shown by use of respiratory accessory muscles, pursed lip breathing,
paradoxical motion of the abdomen, or retraction of intercostal spaces).
• Persistent hypoxaemia despite supplemental oxygen.
Consider the patient’s escalation policy and 'ceilings of care' before starting ventilation.
Follow your hospital’s protocol for initiation of NIV and subsequent management.#
• This will include recommendations on pressures, oxygen titrations, and frequency of ABGs.

• In the UK, in line with recommendations from the British Thoracic Society , for patients who
meet the criteria for acute NIV start treatment within:[91] [102]
• 60 minutes of the blood gas result associated with the clinical decision to go ahead with
treatment
• 120 minutes of hospital arrival for patients who present acutely.
Only consider invasive mechanical ventilation after careful consideration and discussion
with the senior medical team . Bear in mind existing escalation strategies and any advance
directives.[1]
MANAGEMENT
Antibiotics
Give antibiotics to any patient who needs ventilation (invasive or non-invasive) or patients
experiencing exacerbations with: [1]
disease Management
• Increase in sputum volume , plus
• Increase in sputum purulence , and/or
• Increase in dyspnoea .
• Still give antibiotics if the patient has only two of the cardinal symptoms if increased sputum
purulence is one of them.[1]
• Choice of antibiotic should be based on local resistance pat terns , any previous culture
results for the individual patient,[1] and local antibiotic guidelines .
• Duration of therapy should be 5 to 7 days, but consult your local guidelines. [1]
• Give oral antibiotics first-line if possible and if the severity of the exacerbation does not require
intravenous antibiotics.[1] [95] If intravenous antibiotics are given, review them within 48 hours and
consider stepping down to oral antibiotics where possible.[95]
Supplemental treatment for all patients

• Monitor fluid balance.
• Offer nicotine replacement therapy to all current smokers while in hospital and discuss
smoking cessation options for after discharge.[88]
• Treat any comorbidities.
• Consider prophylaxis against thromboembolism.
• Consider nutritional supplements.
Full Recommendations
Treatment goals
The main treatment goals are to:
• Alleviate the patient's symptoms of dyspnoea

• Stabilise and improve respiratory status
• Minimise the impact of the current exacerbation on the patient’s overall health[1]
• Prevent subsequent exacerbations[1]
• Manage any underlying conditions.
Treatment set ting

There are no absolute criteria to determine the most appropriate treatment set ting.
• Consider the full clinical picture in the context of the patient’s usual state.
• Consult senior colleagues if you are uncertain of the best treatment setting.
• See Diagnostic recommendations for specific advice on when to admit to hospital.
Initial pharmacological management
Inhaled bronchodilators
MANAGEMENT
Give a short-acting beta-2 agonist (e.g., salbutamol) at an increased dose or frequency from
the patient’s usual baseline treatment as first-line therapy. [1] [88]
• For a moderate to severe exacerbation, use a nebuliser driven on air (not ox ygen) .[88]
45
disease Management
• This is to avoid worsening hypercapnia.[88]
• The driving gas for nebulised therapy should always be specified in the prescription.[88]
• For a mild exacerbation, use an MDI plus spacer .
• People with severe dyspnoea with low inspiratory flow rates may have difficulty achieving
proper technique and medication delivery from the MDI; a nebuliser may be easier for these
patients to use.
• You may see benefit from this initial treatment within 30 minutes .
During the COVID-19 pandemic, seek advice from a respiratory specialist and consult local guidelines
before using a nebuliser.
• There are currently differences of opinion between organisations in different countries on whether
use of a nebuliser is an aerosol-generating procedure.
• International guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD)
recommend minimal use of nebulisers, advising that inhalers should ideally be used for drug
delivery instead. GOLD acknowledges that nebulisers may be needed in critically ill patients with
COVID-19 receiving ventilatory support. GOLD recommends using a mesh nebuliser (to keep the
circuit intact and prevent virus transmission) if absolutely necessary to do so (e.g., in ventilated
patients).[1] However, nebulisers are not considered to represent a significant infectious risk for
COVID-19 according to Public Health England and the UK National Institute for Health and Care
Excellence.[126] [127]
• For more detailed information on COVID-19 see our topic [Coronavirus disease 2019 (COVID-19).]
Practical tip
Observe patients while they use an MDI. It is common for patients to need advice and training on
technique. If a patient is struggling to obtain the required dose, switch to a nebuliser.
Add a short-acting muscarinic antagonist (e.g., ipratropium) administered via a nebuliser

if the initial dose of the short-acting beta-2 agonist does not provide sufficient and prompt
benefit. [1] [124]
• Short-acting beta-2 agonists are typically favoured as a first-line option as they tend to have a
more rapid effect than antimuscarinics.
Give ipratropium alone if the patient experiences adverse effects due to salbutamol (e.g.,
tremor, palpitations, headache, nausea, dizziness).
To avoid overdose, stop any long-acting muscarinic antagonist the patient may already be on
for maintenance therapy (e.g., aclidinium, glycopyrronium, tiotropium, umeclidinium) while
the short-acting muscarinic antagonist is given.
• Continue the long-acting beta-2 agonist (the patient’s maintenance therapy) alongside
the additional short-acting beta-2 agonist needed for recovery from the exacerbation.
• Many patients are on a long-acting beta-2 agonist/long-acting muscarinic antagonist (with or
MANAGEMENT
without a corticosteroid) combination inhaler for maintenance therapy. If this is the case, stop the
combination inhaler during the acute exacerbation.
disease Management
Seek specialist advice on the optimal method of delivering bronchodilators (MDI or
nebuliser) to adults with COPD exacerbation who are receiving mechanical ventilation via
endotracheal tube.
• There is insufficient evidence to recommend one route of delivery over the other.[128]
Systemic corticosteroids
Consider a systemic (oral or intravenous) corticosteroid. [1] [88] Oral administration is preferred;
however, some patients may require intravenous administration if they cannot tolerate oral therapy (e.g., if
they are vomiting).
• National Institute for Health and Care Excellence (NICE) and Global Initiative for Chronic
Obstructive Lung Disease (GOLD) guidelines recommend a 5-day treatment course .[1] [88]
• Latest evidence shows no benefit from prolonged therapy.[129]
• Corticosteroids are associated with risk of pneumonia, sepsis, and death and should only be used
in patients with significant exacerbations.[1]
• Avoid use of a corticosteroid with a fluoroquinolone antibiotic, because co-administration could
exacerbate fluoroquinolone-induced tendinitis and tendon rupture.[130]
Evidence: Corticosteroids
Evidence shows no benefit from prolonged therapy of corticosteroids.
A Cochrane review compared the efficacy of short-duration (7 or fewer days) and

conventional longer-duration (longer than 7 days) systemic corticosteroid treatment of
adults with acute exacerbations of COPD. [129]
• Eight studies with 582 participants were included.

• Corticosteroid treatment was given at equivalent daily doses for 3 to 7 days for short-duration
treatment and for 10 to 15 days for longer-duration treatment.
• Patients treated for 7 or fewer days did not have a higher rate of treatment failure.
• Time in hospital and lung function at the end of treatment were not different.
• No differences in side effects or death were noted between treatments.
The balance of risks and benefits of corticosteroids for people with milder exacerbations
is uncertain.
• Note that there may be guidance in future over which patients to prescribe corticosteroids to, in
an effort to reduce their prescription.
• At the moment there is no consensus owing to a lack of peer-reviewed data. Eosinophil count
may become a useful determinant of this.[131]
Evidence: The role of methylxanthines

MANAGEMENT
The use of methylxanthines is not routinely recommended.
GOLD states that methylxanthines (theophylline or aminophylline) are not recommended

due to their side-effect profile. [1] #
47
disease Management
NICE states that intravenous theophylline should only be used as an adjunct
to exacerbation management if there is an inadequate response to nebulised
bronchodilators, noting that there is potential for toxicity in patients already taking oral
theophylline and that levels should be monitored. [88]
A meta-analysis of four randomised controlled trials found no consistent benefit from

taking a methylxanthine to treat an exacerbation of COPD, but that they were associated
with an increase in nausea and vomiting. [132] #
• The risks of nausea or vomiting were significantly higher for patients receiving a methylxanthine
(OR 4.6, 95% CI 1.7 to 12.6) than for patients receiving placebo.[132]
In a trial to assess whether theophylline helps to prevent exacerbations, 1567 participants
were randomised to receive low-dose theophylline or placebo. [133] #
• The main outcome measured was the number of participant-reported moderate or severe
exacerbations treated with antibiotics, oral corticosteroids, or both over a 1-year treatment
period.
• It found that among adults with COPD at high risk of exacerbation treated with inhaled
corticosteroids, the addition of low-dose theophylline, compared with placebo, did not reduce the
number of COPD exacerbations over a 1-year period.
• In total, there were 3430 exacerbations:
• 1727 in the theophylline group (mean exacerbations per year 2.24, 95% CI 2.10 to
2.38)
• 1703 in the placebo group (mean exacerbations per year 2.23, 95% CI 2.09 to
2.37).
• The findings do not support the use of low-dose theophylline as adjunctive therapy to inhaled
corticosteroids for the prevention of COPD exacerbations.
Assess severity
Assess severity to determine where and how to treat the patient.[1] [88]
• Use pulse oximetry and ABG , acknowledging that values will need to be compared against the
patient’s baseline .
• Consider the patient's prior status and any changes to previous baseline investigation (based on
symptoms, examination, and investigations).
• Take into account frailty and comorbidities .
See Diagnostic recommendations for specific advice on how to stratify exacerbations (into mild,
moderate, and severe) and the impact of this on management.
Respiratory support
MANAGEMENT
disease Management
Ox ygen
Check arterial blood gas and pulse oximetry on presentation and then after 30 to 60 minutes
to ensure satisfactory ox ygenation and monitor for carbon dioxide retention and acidosis.
[1] [96] #
• Administer the oxygen in a controlled fashion via a Venturi mask to deliver 24% to 28%
oxygen.[96]
• Titrate controlled ox ygen to a target saturation of 88% to 92% as COPD patients are
considered at risk for hypercapnic (type 2) respiratory failure.[1] [96] [100]
• Document the FiO₂ or O₂ flow rate.
Repeat ABG if the patient's clinical condition deteriorates or they fail to respond to initial
therapy.
Avoid excessive ox ygen use in patients with COPD due to the risk of hypercapnic (type 2)
respiratory failure.
• It is likely there are at least six mechanisms responsible for oxygen-induced hypercapnia:[96]
• V/Q mismatch
• Ventilatory drive
• Haldane effect (the ability of deoxyhaemoglobin to carry more carbon dioxide than
oxyhaemoglobin[134])
• Absorption atelectasis
• Higher density of oxygen compared with air
• Rebreathing can occur if low oxygen flow rates are used through a face mask.
• Risk factors for hypercapnic respiratory failure include:
• Previous respiratory failure

• Morbid obesity[96]
• Chest wall deformities, such as severe kyphoscoliosis[96]
• Neuromuscular disorders[96]
• Fixed airflow obstruction associated with bronchiectasis[96]
• Concurrent obstructive sleep apnoea.
• The risk of respiratory acidosis in patients with hypercapnic respiratory failure is increased if
the PaO₂ is above 10.0 kPa (75 mmHg) due to previous excessive oxygen use.[96]
Use a Venturi mask in preference to nasal prongs as they offer a more accurate delivery of
ox ygen. [1] #
• More evidence is needed on the use of high-flow oxygen therapy by nasal cannula in patients with
acute exacerbations of COPD.[1]
Practical tip
MANAGEMENT
49
disease Management
Beware that hypercapnic respiratory failure may occur as a consequence of high oxygen delivery in
an ambulance when attempting hypoxaemia correction.[125] Note that nasal prongs and standard
Hudson masks do not deliver controlled oxygen.
Gradually reduce ox ygen therapy as the patient recovers. [96]
Discontinue ox ygen therapy once the patient can maintain their target ox ygen saturation on
room air. [96]
• Bear in mind that some patients will be on long-term ox ygen therapy as part of their usual
treatment and this will need to be maintained.
Ventilation
Non-invasive ventilation (NIV)
Start NIV for patients with acute hypercapnic respiratory failure (pH <7.35, PaCO₂ >6.5 kPa),
despite optimal medical therapy [100] #with no contraindications. [1] #
• NIV:[1] [135] [Evidence B]
• Improves survival
• Improves gas exchange
• Reduces the work of breathing
• Reduces the need for intubation
• Decreases length of hospital stay.
Provide non-invasive mechanical ventilation to patients with any of the following: [1] #
• Respiratory acidosis (pH <7.35 and PaCO₂ >6.5 kPa).[100]
• The evidence is less clear for patients with arterial pH ≤7.25. In these patients NIV may be
used as a 'ceiling of care' treatment for severe hypercapnic acidaemic ventilatory failure.
• Severe dyspnoea (as shown by use of respiratory accessory muscles, paradoxical motion of the
abdomen, or retraction of intercostal spaces).
• Persistent hypoxaemia despite supplemental oxygen.
Follow your hospital’s protocol for initiation of NIV and subsequent management.#
• This should include recommendations on pressures, oxygen titrations, and frequency of ABGs.
In general:
• Monitor ox ygen saturations continuously. [100] #

MANAGEMENT
• Take intermit tent measurements of PaCO₂ and pH. [100] #

• Use ECG monitoring if the patient has a pulse rate >120 bpm or if there is dysrhythmia
or possible cardiomyopathy. [100]
• Frequently assess the patient to monitor for any complications occurring.
disease Management
The British Thoracic Society sets out specific timeframes as measurable markers of good
practice for the use of acute NIV in the UK. [91] [102] #
• For patients who meet the criteria for acute NIV , start it within :
• 60 minutes of the blood gas result associated with the clinical decision to go ahead with
NIV
• 120 minutes of hospital arrival for patients who present acutely.
• Review the patient’s clinical progress within 4 hours of starting NIV .
• This should be done by a healthcare professional with appropriate training and competence.
• A consultant with training and competence in acute NIV should review the patient’s clinical
progress within 14 hours of starting acute NIV .
If possible, perform a blood gas analysis within 30-60 minutes of starting acute NIV.
• Although the British Thoracic Society (BTS) recommends performing blood gas analysis within 2
hours of starting acute NIV, [102] in practice, specialists recommend ideally waiting only 30-60
minutes to check for changes in PaCO 2 and pH. [102]
• Arrange review by a specialist healthcare professional with expertise in managing patients on
NIV within 30 minutes if blood gas measurements fail to improve.
Plan with senior colleagues what to do if the patient deteriorates,[100] including 'ceilings of care'
,[88] and consider DNACPR (‘Do Not Attempt Cardiopulmonary Resuscitation’) for patients not suitable
for escalation to an intensive care unit.
• See Diagnostic recommendations for specific advice on care planning.

Admit the patient to an intensive care unit if they have:[1]
• Severe dyspnoea with a poor response to initial emergency therapy

• Changes in mental status
• Persistent or worsening hypoxaemia (PaO 2 <40 mmHg or 5.3 kPa) and/or severe or worsening
respiratory acidosis (pH <7.25) despite supplemental oxygen and non-invasive ventilation
• Need for invasive mechanical ventilation
• Haemodynamic instability (need for vasopressors).
Invasive mechanical ventilation

Only consider invasive ventilation after careful consideration and discussion with the
senior medical team. [1] #
• This is not purely a clinical decision and there are no absolute numerical thresholds to adhere to.
You will need to take many factors into account, including the patient’s own wishes regarding
resuscitation.
MANAGEMENT
• Compare the patient’s functional status to their baseline and consider their overall fitness for
ventilation.
• Indications for invasive mechanical ventilation include:[1]
• Unable to tolerate NIV
51
disease Management
• When NIV has failed
• Post respiratory arrest or cardiac arrest
• Diminished consciousness or inadequately controlled psychomotor agitation
• Massive aspiration or persistent vomiting
• Persistent respiratory secretions that cannot be removed
• Severe haemodynamic instability, not successfully treated with fluid and drugs
• Severe arrhythmias
• Hypoxaemia and unable to tolerate NIV.
• Complications associated with mechanical ventilation include:[1]
• Ventilator-associated pneumonia
• Barotrauma
• Volutrauma
• Respiratory weakness after prolonged ventilation (weaning and tracheostomy may be
required to manage this).
Patient suitability
When assessing suitability for intubation and ventilation , take into account:[88]
• Functional status
• BMI
• Need for oxygen when stable
• Comorbidities
• Previous admissions to intensive care units
• Age
• FEV₁.
• Do not use age or FEV₁ in isolation when assessing suitability for intubation and ventilation.
Treat the underlying cause

Give antibiotics to any patient who needs ventilation (invasive or non-invasive) or patients
experiencing exacerbations with: [1] #
• Increase in sputum purulence , plus

• Increase in sputum volume , and/or
• Increased dyspnoea .
As well as the severity of symptoms, particularly sputum colour changes and increases in
volume or thickness beyond the patient’s normal day-to-day variation, NICE urges you to also
consider: [95] #
• Whether the patient needs to go into hospital for treatment

MANAGEMENT
• Previous exacerbation and hospital admission history

• Risk of developing complications
• Previous sputum culture and susceptibility results
• Risk of antimicrobial resistance with repeated courses of antibiotics.
disease Management
Choose an antibiotic regimen based on local resistance pat terns, any previous culture
results for the individual patient, [1] #and local antibiotic guidelines.
• Duration of therapy will tend to be 5 to 7 days, but consult your local guidelines. [1] #
• More recent guidance from the American College of Physicians recommends limiting
antibiotic treatment to 5 days in patients with COPD exacerbations and acute uncomplicated
bronchitis.[138]
• When used appropriately, antibiotics can:[1]
• Shorten recovery time

• Reduce the risk of early relapse and treatment failure
• Shorten the length of hospital stay.
Give oral antibiotics first-line if the patient is able to tolerate oral medications, and if the
severity of the exacerbation does not require intravenous antibiotics. [1] [95]
• If a patient is started on intravenous antibiotics, review them by 48 hours and consider stepping
down to oral therapy where possible.[95]
• NICE recommends amoxicillin, doxycycline, or clarithromycin as suitable first-line oral options.
Alternative oral options include amoxicillin/clavulanate, levofloxacin, and trimethoprim/
sulfamethoxazole. Suitable first-line intravenous options include amoxicillin, amoxicillin/
clavulanate, clarithromycin, trimethoprim/sulfamethoxazole, or piperacillin/tazobactam.[95]
• It is worth noting that you must not prescribe fluoroquinolones (e.g., levofloxacin) for mild to
moderate acute exacerbation of COPD unless other antibiotics are considered inappropriate. This
is due to reports of disabling, long-lasting, or potentially irreversible adverse reactions affecting
the musculoskeletal and nervous systems.[130] [139] Avoid fluoroquinolones in patients who
have previously had serious adverse effects with a fluoroquinolone antibiotic. Avoid use of a
corticosteroid with a fluoroquinolone, because co-administration could exacerbate fluoroquinolone-
induced tendinitis and tendon rupture.[130]
Look for improvements in dyspnoea and sputum purulence to measure success of antibiotic
treatment. [1]
Additional considerations in the community

Give the patient/their family specific advice about when to seek further medical help, in
particular: [95]
• If symptoms worsen rapidly or significantly

• If symptoms do not start to improve within an agreed time (e.g., 2 to 3 days if taking antibiotics)
• If the patient becomes systemically very unwell .
Give advice on possible adverse effects of antibiotics (particularly diarrhoea). [95]
Explain that their respiratory symptoms may not be fully resolved when the course has been
MANAGEMENT
completed.[95]
Reassess the patient if their symptoms worsen rapidly or significantly. In particular:
• Beware symptoms and signs of:
53
disease Management
• Pneumonia
• Cardiorespiratory failure
• Sepsis .
• Refer the patient to hospital if you suspect a more serious illness (e.g., sepsis or
cardiorespiratory failure).
Consider antibiotic-resistant bacteria and send a sputum sample for microscopy, culture,
and Gram stain if symptoms have not improved following antibiotic treatment and these tests
have not been done already. [95] #
• Only request sputum microscopy, culture, and Gram stain in severe disease and if hospitalisation
is being considered. This is not a routine investigation in primary care .[88]
Seek specialist advice for patients: [95] #
• Whose symptoms do not improve after repeated courses of antibiotics

• With a bacterial infection resistant to oral antibiotics
• Who cannot take oral medications .
• Other options may be to give intravenous antibiotics at home or in the community, rather than
in hospital, where appropriate.
Some patients will keep antibiotics at home for use in an exacerbation as part of their
existing action plan.
Evidence: Efficacy of antibiotics[140]#
Antibiotics offer a large and consistent beneficial effect across outcomes of patients admitted to an
intensive care unit (ICU), but for inpatients and outpatients the effects are inconsistent.
A#Cochrane review of 19 trials with 2663 participants looked at the effects of antibiotics in
the management of acute COPD exacerbations on:#
• Treatment failure (observed 7 days to 1 month after treatment initiation)

• Mortality
• Length of hospital stay.
In the study:
• Three groups of patients were considered:
• Outpatients (mild to moderate exacerbation)

• Inpatients (severe exacerbation)
• ICU patients (very severe exacerbation)
• In outpatients, there was low-quality evidence that antibiotics do significantly reduce the risk for
MANAGEMENT
treatment failure between 7 days and 1 month after treatment initiation (RR 0.72, 95% CI 0.56 to
0.94).
disease Management
• In inpatients (excluding ICU), moderate-quality evidence does not show that antibiotics
significantly reduce the risk of treatment failure in inpatients with severe exacerbations (RR 0.65,
95% CI 0.38 to 1.12).
• In ICU patients:
• A trial of 93 patients showed a large and statistically significant effect of antibiotics on

treatment failure (RR 0.19, 95% CI 0.08 to 0.45)
• Antibiotics significantly reduced length of hospital stay (mean difference ‐9.60 days, 95%
CI ‐12.84 to ‐6.36 days).
• Length of hospital stay (in days) was similar in the antibiotic and placebo groups for inpatients.
• The authors conclude that there is beneficial effect across outcomes of patients admitted to an
ICU, but that for inpatients and outpatients the effects of antibiotics are inconsistent.[140]
Evidence: Choice of antibiotic
Many antibiotics have been found to be effective for the treatment of an acute exacerbation of COPD.
A review of 19 randomised controlled trials (RCTs) found that macrolides,

fluoroquinolones, and amoxicillin/clavulanate may be considered equivalent for the
treatment of patients with an acute bacterial exacerbation of chronic bronchitis in short-
term effectiveness. [141]
• Treatment success was lower for macrolides compared with fluoroquinolones (OR 0.47, 95% CI
0.31 to 0.69).
• Fewer fluoroquinolone recipients experienced a recurrence of acute exacerbation after
resolution of the initial episode, compared with macrolide recipients, during the 26-week period
following therapy.
• Amoxicillin/clavulanate was associated with more adverse effects (mainly diarrhoea) than
fluoroquinolones (OR 1.36, 95% CI 1.01 to 1.85).
An analysis of five RCTs involving 287 patients found that there were no differences
between patients with acute exacerbation of chronic bronchitis receiving semisynthetic
penicillins (e.g., amoxicillin, ampicillin) and those receiving trimethoprim-based regimens
(e.g., trimethoprim, trimethoprim/sulfamethoxa zole, trimethoprim/sulfadia zine) in: [142] #
• Treatment success (intention-to-treat patients: n = 262; OR 1.68, 95% CI 0.91 to 3.09; clinically
evaluable patients: n = 246; OR 1.59, 95% CI 0.79 to 3.20)
• Number of drug-related adverse events in general (n = 186 patients; OR 0.37, 95% CI 0.11 to
1.24).
Choose an antibiotic regimen based on local resistance pat terns, any previous culture
results for the individual patient, [1] #and local antibiotic guidelines.#
Supplemental treatment in hospital

MANAGEMENT
Monitor fluid balance.
• This may be particularly important in patients with comorbidities, such as heart failure.
Depending on the patient’s clinical condition, you may need to:[1] #
55
disease Management
• Treat any comorbidities
• Comorbidities, such as lung cancer, cardiovascular disease, osteoporosis, and depression,

are common in patients with COPD
• Consider any other drugs the patient is taking
• Administer prophylaxis against thromboembolism, if needed
• Give nutritional supplements
• Patients with COPD who are undernourished are at an increased risk of exacerbations.[143]
Ongoing management and discharge
Monitor recovery
Regularly assess symptoms and observe the patient’s functional status. [88] #
• Use intermit tent ABG measurements to monitor the recovery of people with respiratory
failure who are hypercapnic or acidotic , until they are stable with a normalised pH.[88]
• Use pulse oximetry to monitor the recovery of people with non-hypercapnic, non-acidotic
respiratory failure .[88]
• Do not use daily monitoring of peak expiratory flow or FEV₁ to monitor recovery from
an exacerbation, because the magnitude of change is small compared with the variability of the
measurement.[88]
Practical tip
Change drug delivery from a nebuliser to an MDI once the patient has stabilised. This may allow an
earlier discharge from hospital.
Discharge planning
You (along with the patient and family) should be confident that the patient can manage
their symptoms at home before they are discharged.
• If the patient smokes, reinforce the advice to the patient that they must stop smoking and provide
information on how to access the services that help with this.[144]
• Offer a 'harm reduction' approach, such as reducing the number of cigaret tes
smoked or temporary abstinence . This may be a practical step for patients struggling to
quit.[145]
• Review the patient’s long-term medication.
• Re-establish people on their optimal maintenance bronchodilator therapy before

discharge.[88]
MANAGEMENT
• Provide vitamin D supplementation, if required. Supplementation of patients with severe deficiency

results in a reduction in exacerbations and hospitalisation.[1]
• Consider a hospital-at-home or assisted discharge scheme, where available, once the
patient is stable .[88] [146] [147]
disease Management
• The decision over which patients are suitable for such schemes will need a team approach,
as will the implementation of such schemes. Take patient factors and preferences into
account.[88] Consider using a validated prognostic score, such as the DECAF (Dyspnoea,
Eosinopenia, Consolidation, Acidaemia, and atrial Fibrillation) score, to determine which
patients are suitable for this approach.[146]
• Be aware that patients who have suffered from a significant exacerbation of COPD may not always
recover back to their pre-illness functional status. Discuss this as needed with the patient and their
family, so that their expectations of the duration and extent of recovery are realistic.
• Refer for a pulmonary rehabilitation programme, as required , to improve exercise
tolerance, physical ability, and quality of life.[148]
• Pulmonary rehabilitation is a multidisciplinary programme of care that involves physical

rehabilitation as well as guidance on disease management, nutrition, and other lifestyle
issues (e.g., smoking cessation, medicine compliance and inhaler technique, supplemental
oxygen, and maintenance of physical activity).[149]
Prior to discharge: [1] [88]
• Review all clinical data and test results : identify and manage any abnormalities.
• Measure (or review previous) spirometry in all patients.[91] During periods of high prevalence
of COVID-19 in the community, spirometry should be restricted to patients requiring urgent or
essential tests for the diagnosis of COPD, and/or to assess lung function status for interventional
procedures or surgery.[1] [97] Performing spirometry and pulmonary function testing may lead to
SARS-CoV-2 transmission as a result of droplet and aerosol formation during the tests, especially
with coughing.
• Ensure satisfactory oximetry or ABG results in patients who have had an episode of
respiratory failure.
• Assess the need for continuing ox ygen therapy .
• Check the patient’s understanding of the withdrawal of their acute medications and their
re-established maintenance therapy .
• Give appropriate information on the correct use of medications and oxygen.
• Reassess inhaler technique .
• Provide a management plan for comorbidities .
• Make arrangements for follow-up and home care .
Practical tip
Although there are insufficient data that specific 'care bundles' at hospital discharge reduce
readmission rates, improve mortality, or are cost-effective,[1] the general principles are all worth
considering as part of discharge and follow-up:
• Education
• Optimisation of medication
• Supervision and correction of inhaler technique
MANAGEMENT
• Assessment and management of comorbidities

• Early rehabilitation
• Telemonitoring
57
disease Management
• Continuing patient contact.
Evidence: Pulmonary rehabilitation
Pulmonary rehabilitation was found to be a safe intervention to improve quality of life and exercise
capacity for patients with COPD after an exacerbation.
A Cochrane review looked at 20 studies involving 1477 participants with COPD to assess
the impact of pulmonary rehabilitation after an exacerbation of COPD versus usual care.
[148] #
• Quality of life was measured using questionnaires and exercise capacity was measured using
walking tests, such as the 6-minute walk test.
• Eight studies that used the St George’s Respiratory Questionnaire reported a statistically
significant effect on total score.
• Thirteen studies involving 819 participants used the 6-minute walk test. The 6-minute walk
distance improved, on average, by 62 metres (95% CI 38 to 86).
• Six studies including 670 participants contributed data on mortality. The quality of evidence was
low. Meta‐analysis showed no statistically significant effects of rehabilitation on mortality (pooled
OR 0.68, 95% CI 0.28 to 1.67).
• Eight studies involving 810 participants contributed data on hospital readmissions. Moderate‐
quality evidence showed that pulmonary rehabilitation reduced hospital readmission (pooled
OR 0.44, 95% CI 0.21 to 0.91). However, of the eight studies, four showed large and statistically
significant reductions in the risk of hospital admission associated with pulmonary rehabilitation,
and four showed no effect.
Treatment algorithm overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Acute ( summary )
on presentation
1st short-acting bronchodilator
consider systemic corticosteroid
consider ox ygen
consider ventilation
consider antibiotic therapy
consider supplemental treatment

MANAGEMENT
disease Management
Ongoing ( summary )
after stabilisation
1st monitor recovery and plan discharge
MANAGEMENT
59
disease Management
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
MANAGEMENT
disease Management
Acute
on presentation
1st short-acting bronchodilator

Primary options
» salbutamol inhaled: (100 micrograms/

dose inhaler) 2-10 puffs inhaled every 10-20
minutes or when required (each puff should
be inhaled separately via a large volume
spacer); 5 mg inhaled via nebuliser every
20-30 minutes or when required
-and/or-
» ipratropium inhaled: 500 micrograms
inhaled via nebuliser when required, may
repeat dose until patient is stable (time
interval between doses may be determined
by physician), maximum 2 mg/day
» Give a short-acting beta-2 agonist

(e.g., salbutamol) at an increased dose
or frequency from the patient’s usual
baseline treatment as first-line therapy. [1]
[88]
• For a moderate to severe exacerbation,

use a nebuliser driven on air (not
ox ygen) .[88]
• This is to avoid worsening

hypercapnia.[88]
• The driving gas for nebulised
therapy should always be specified
in the prescription.[88]
• For a mild exacerbation, use a metered-
dose inhaler (MDI) plus spacer .
• People with severe dyspnoea with
low inspiratory flow rates may have
difficulty achieving proper technique
and medication delivery from the MDI;
a nebuliser may be easier for these
patients to use.
• You may see benefit from this initial
treatment within 30 minutes .
» During the COVID-19 pandemic, seek advice
from a respiratory specialist and consult local
guidelines before using a nebuliser.
• There are currently differences of opinion

between organisations in different
MANAGEMENT
countries on whether use of a nebuliser is

an aerosol-generating procedure.
• International guidelines from the Global
Initiative for Chronic Obstructive Lung
Disease (GOLD) recommend minimal use
61
disease Management
Acute
of nebulisers, advising that inhalers should
ideally be used for drug delivery instead.
GOLD acknowledges that nebulisers may
be needed in critically ill patients with
COVID-19 receiving ventilatory support.
GOLD recommends using a mesh
nebuliser (to keep the circuit intact and
prevent virus transmission) if absolutely
necessary to do so (e.g., in ventilated
patients).[1] However, nebulisers are
not considered to represent a significant
infectious risk for COVID-19 according
to Public Health England and the UK
National Institute for Health and Care
Excellence.[126] [127]
• For more detailed information on
COVID-19 see our topic [Coronavirus
disease 2019 (COVID-19).]
Practical tip
Observe patients while they use an MDI.

It is common for patients to need advice
and training on technique. If a patient is
struggling to obtain the required dose,
switch to a nebuliser.
» Add a short-acting muscarinic

antagonist (e.g., ipratropium) administered
via a nebuliser if the initial dose of the
short-acting beta-2 agonist does not
provide sufficient and prompt benefit. [1]
[124]
• Short-acting beta-2 agonists are

typically favoured as a first-line option as
they tend to have a more rapid effect
than antimuscarinics.
» Give ipratropium alone if the patient
experiences adverse effects due to
salbutamol (e.g., tremor, palpitations,
headache, nausea, dizziness).
» To avoid overdose, stop any long-

acting muscarinic antagonist the patient
may already be on for maintenance
therapy (e.g., aclidinium, glycopyrronium,
tiotropium, umeclidinium) while the short-
acting muscarinic antagonist is given.
• Continue the long-acting beta-2

MANAGEMENT
agonist (the patient’s maintenance

therapy) alongside the additional short-
acting beta-2 agonist needed for recovery
from the exacerbation.
disease Management
Acute
• Many patients are on a long-acting beta-2
agonist/long-acting muscarinic antagonist
(with or without a corticosteroid)
combination inhaler for maintenance
therapy. If this is the case, stop the
combination inhaler during the acute
exacerbation.
» Seek specialist advice on the optimal
method of delivering bronchodilators
(MDI or nebuliser) to adults with
COPD exacerbation who are receiving
mechanical ventilation via endotracheal
tube.
• There is insufficient evidence to

recommend one route of delivery over the
other.[128]
consider systemic corticosteroid

Treatment recommended for SOME patients in
selected patient group
Primary options
» prednisolone: 30 mg orally once daily
OR
» hydrocortisone sodium succinate: 100 mg

intravenously every 6 hours; convert to oral
prednisolone as soon as possible to complete
course
» Consider a systemic (oral or

intravenous) corticosteroid. [1] [88] Oral
administration is preferred; however, some
patients may require intravenous administration
if they cannot tolerate oral therapy (e.g., if they
are vomiting).
• National Institute for Health and Care

Excellence and Global Initiative for
Chronic Obstructive Lung Disease
(GOLD) guidelines recommend a 5-day
treatment course .[1] [88]
• Latest evidence shows no benefit from
prolonged therapy.[129]
• Corticosteroids are associated with risk of
pneumonia, sepsis, and death and should
MANAGEMENT
only be used in patients with significant

exacerbations.[1]
• Avoid use of a corticosteroid with a
fluoroquinolone antibiotic, because
co-administration could exacerbate
63
disease Management
Acute
fluoroquinolone-induced tendinitis and
tendon rupture.[130]
Evidence: Corticosteroids
Evidence shows no benefit from prolonged

therapy of corticosteroids.
A Cochrane review compared the

efficacy of short-duration (7 or
fewer days) and conventional longer
duration (longer than 7 days) systemic
corticosteroid treatment of adults with
acute exacerbations of COPD. [129] #
• Eight studies with 582 participants

were included.
• Corticosteroid treatment was given
at equivalent daily doses for 3 to 7
days for short-duration treatment and
for 10 to 15 days for longer-duration
treatment.
• Patients treated for 7 or fewer days
did not have a higher rate of treatment
failure.
• Time in hospital and lung function at
the end of treatment were not different.
• No differences in side effects or death
were noted between treatments.
The balance of risks and benefits of
corticosteroids for people with milder
exacerbations is uncertain.
• Note that there may be guidance in

future over which patients to prescribe
corticosteroids to, in an effort to reduce
their prescription.
• At the moment there is no consensus
owing to a lack of peer-reviewed data.
Eosinophil count may become a useful
determinant of this.[131]
consider ox ygen
MANAGEMENT
» Check arterial blood gas and pulse

oximetry on presentation and then after
30 to 60 minutes to ensure satisfactory
ox ygenation and monitor for carbon
dioxide retention and acidosis. [1] [96] #
disease Management
Acute
• Administer the oxygen in a controlled
fashion via a Venturi mask to deliver
24% to 28% oxygen.[96]
• Titrate controlled ox ygen to a target
saturation of 88% to 92% as COPD
patients are considered at risk for
hypercapnic (type 2) respiratory failure.[1]
[96] [100]
• Document the fraction of inspired oxygen
(FiO₂) or O₂ flow rate.
» Repeat arterial blood gas (ABG) if the
patient's clinical condition deteriorates or
they fail to respond to initial therapy.
» Avoid excessive ox ygen use in patients

with COPD due to the risk of hypercapnic
(type 2) respiratory failure.
• It is likely that there are at least six

mechanisms responsible for oxygen-
induced hypercapnia:[96]
• V/Q mismatch
• Ventilatory drive
• Haldane effect (the ability of
deoxyhaemoglobin to carry
more carbon dioxide than
oxyhaemoglobin[134])
• Absorption atelectasis
• Higher density of oxygen compared
with air
• Rebreathing can occur if low
oxygen flow rates are used through
a face mask.
• Risk factors for hypercapnic respiratory
failure include:
• Previous respiratory failure

• Morbid obesity[96]
• Chest wall deformities, such as
severe kyphoscoliosis[96]
• Neuromuscular disorders[96]
• Fixed airflow obstruction associated
with bronchiectasis[96]
• Concurrent obstructive sleep
apnoea.
MANAGEMENT
• The risk of respiratory acidosis in

patients with hypercapnic respiratory
failure is increased if the PaO 2 is
above 10.0 kPa (75 mmHg) due to
previous excessive oxygen use.[96]
65
disease Management
Acute
» Use a Venturi mask in preference to
nasal prongs as they offer a more accurate
delivery of ox ygen. [1] #
• More evidence is needed on the use of

high-flow oxygen therapy by nasal cannula
in patients with acute exacerbations of
COPD.[1]
Practical tip
Beware that hypercapnic respiratory

failure may occur as a consequence of
high oxygen delivery in an ambulance
when attempting hypoxaemia
correction.[125] Note that nasal prongs
and standard Hudson masks do not deliver
controlled oxygen.
» Gradually reduce ox ygen therapy as the

patient recovers. [96]
» Discontinue ox ygen therapy once the

patient can maintain their target ox ygen
saturation on room air. [96]
• Bear in mind that some patients will be

on long-term ox ygen therapy as part
of their usual treatment and this will need
to be maintained.
consider ventilation
» Start non-invasive ventilation (NIV) for
patients who have acute hypercapnic
respiratory failure (pH <7.35, PaCO 2 >6.5
kPa), despite optimal medical therapy,
[100] #and have no contraindications. [125]
• NIV:[1] [147] [Evidence B]
• Improves survival
• Improves gas exchange
• Reduces the work of breathing
• Reduces the need for intubation
• Decreases length of hospital stay.
» Provide non-invasive mechanical

MANAGEMENT
ventilation to patients with any of the

following: [1] #
• Respiratory acidosis (pH <7.35 and

PaCO 2 >6.5 kPa).[100]
disease Management
Acute
• Acidaemia implies a severe
exacerbation and predicts in-
hospital and 30-day mortality.[101]
• The evidence is less clear for
patients with arterial pH ≤7.25. In
these patients NIV may be used
as a ceiling of care treatment for
severe hypercapnic acidaemic
ventilatory failure.
• Severe dyspnoea (as shown by use
of respiratory accessory muscles,
paradoxical motion of the abdomen, or
retraction of intercostal spaces).
• Persistent hypoxaemia despite
supplemental oxygen.
» Follow your hospital’s protocol
for initiation of NIV and subsequent
management.#
• This should include recommendations

on pressures, oxygen titrations, and
frequency of ABGs.
» In general:
• Monitor ox ygen saturations

continuously. [100] #
• Take intermit tent measurements of
PaCO 2 and pH. [100] #
• Use ECG monitoring if the patient
has a pulse rate >120 bpm or if
there is dysrhythmia or possible
cardiomyopathy. [100] #
• Frequently assess the patient to
monitor for any complications
occurring.
» The British Thoracic Society sets
out specific timeframes as measurable
markers of good practice for the use of
acute NIV in the UK. [91] [102] #
• For patients who meet the criteria for

acute NIV, start it within:
• 60 minutes of the blood gas

result associated with the clinical
decision to go ahead with NIV
MANAGEMENT
• 120 minutes of hospital arrival

for patients who present acutely.
• Review the patient’s clinical progress
within 4 hours of starting NIV.
67
disease Management
Acute
• This should be done by a
healthcare professional with
appropriate training and
competence.
• A consultant with training and competence
in acute NIV should review the patient’s
clinical progress within 14 hours of
starting acute NIV .
» If possible, perform a blood gas analysis
within 30-60 minutes of starting acute NIV .
• Although the BTS recommends

performing a blood gas analysis within
2 hours of starting NIV,[102] in practice,
specialists recommend ideally waiting only
30-60 minutes to check for changes in
PaCO 2 and pH.
• Arrange review by a specialist healthcare
professional with expertise in managing
patients on NIV within 30 minutes if the
blood gas measurements have failed to
improve.
» Plan with senior colleagues what to
do if the patient deteriorates,[100] including
‘ceilings of care’ ,[88] and consider
DNACPR (‘Do Not Attempt Cardiopulmonary
Resuscitation’) for patients not suitable for
escalation to an intensive care unit.
• See Diagnostic recommendations for

specific advice on care planning.
» Admit the patient to an intensive care unit if
they have:[1]
• Severe dyspnoea with a poor response to

initial emergency therapy
• Changes in mental status
• Persistent or worsening hypoxaemia (PaO
2 <40 mmHg or 5.3 kPa) and/or severe or
worsening respiratory acidosis (pH <7.25)
despite supplemental oxygen and non-
invasive ventilation
• Need for invasive mechanical ventilation
• Haemodynamic instability (need for
vasopressors).
MANAGEMENT
» Only consider invasive ventilation after

careful consideration and discussion with
the senior medical team. [1] #
disease Management
Acute
• This is not purely a clinical decision
and there are no absolute numerical
thresholds to adhere to. You will need to
take many factors into account, including
the patient’s own wishes regarding
resuscitation.
• Compare the patient’s functional status to
their baseline and consider their overall
fitness for ventilation.
• Indications for invasive mechanical
ventilation include:[1]
• Unable to tolerate NIV

• When NIV has failed
• Post respiratory arrest or cardiac
arrest
• Diminished consciousness
or inadequately controlled
psychomotor agitation
• Massive aspiration or persistent
vomiting
• Persistent respiratory secretions
that cannot be removed
• Severe haemodynamic instability,
not successfully treated with fluid
and drugs
• Severe arrhythmias
• Hypoxaemia and unable to tolerate
NIV.
• Complications associated with mechanical
ventilation include:[1]
• Ventilator-associated pneumonia
• Barotrauma
• Volutrauma
• Respiratory weakness after
prolonged ventilation (weaning and
tracheostomy may be required to
manage this).
» When assessing suitability for

intubation and ventilation, take into
account: [88]
MANAGEMENT
• Functional status
• BMI
• Need for oxygen when stable
• Comorbidities
69
disease Management
Acute
• Previous admissions to intensive care
units
• Age
• FEV 1 .
• Do not use age or FEV 1 in isolation

when assessing suitability for
intubation and ventilation.
»
consider antibiotic therapy
Primary options
» amoxicillin: 500 mg orally three times daily,

may increase to 1000 mg three times daily in
severe infections; 500 mg intravenously every
8 hours, may increase to 1000 mg every 6
hours in severe infections
OR
» doxycycline: 200 mg orally on the first day,

followed by 100 mg once daily thereafter,
may increase to 200 mg once daily in severe
infections
OR
» clarithromycin: 500 mg orally (immediate-

release)/intravenously twice daily
Secondary options
» amoxicillin/clavulanate: 500/125 mg orally

three times daily; 1.2 g intravenously every 8
hours
Intravenous dose consists of 1 g of amoxicillin
plus 0.2 g of clavulanate.
OR
» trimethoprim/sulfamethoxazole: 160/800 mg
orally twice daily; 160/800 mg intravenously
every 12 hours, may increase to 240/1200
mg every 12 hours in severe infections
Also known as cotrimoxazole. Should only be
MANAGEMENT
considered in acute exacerbations of COPD

when there is bacteriological evidence of
sensitivity and good reason to prefer this
combination to a single antibiotic. National
Institute for Health and Care Excellence.
Chronic obstructive pulmonary disease (acute
disease Management
Acute
exacerbation): antimicrobial prescribing.
December 2018 [internet publication]. https://
www.nice.org.uk/guidance/ng114
OR
» piperacillin/tazobactam: 4.5 g intravenously

every 8 hours, may increase to 4.5 g every 6
hours in severe infections
Dose consists of 4 g of piperacillin plus 0.5 g
of tazobactam.
OR
» levofloxacin: 500 mg orally once daily for 5

days
» Give antibiotics to any patient who

needs ventilation (invasive or non-
invasive) or patients experiencing
exacerbations with: [1] #
• Increase in sputum purulence , plus

• Increase in sputum volume , and/or
• Increased dyspnoea .
» As well as the severity of symptoms,
particularly sputum colour changes and
increases in volume or thickness beyond
the patient’s normal day-to-day variation,
the National Institute for Health and
Care Excellence (NICE) urges you to also
consider: [95]
• Whether the patient needs to go into

hospital for treatment
• Previous exacerbation and hospital
admission history
• Risk of developing complications
• Previous sputum culture and
susceptibility results
• Risk of antimicrobial resistance with
repeated courses of antibiotics.
» Choose an antibiotic based on local
resistance pat terns, any previous culture
results for the individual patient, [1] #and
local antibiotic guidelines.#
• Duration of therapy will tend to be

5 to 7 days, but consult your local
MANAGEMENT
guidelines. [1]
• More recent guidance from the

American College of Physicians
recommends limiting antibiotic
treatment to 5 days in patients with
71
disease Management
Acute
COPD exacerbations and acute
uncomplicated bronchitis.[138]
• When used appropriately, antibiotics
can:[1]
• Shorten recovery time

• Reduce the risk of early relapse and
treatment failure
• Shorten the length of hospital stay.
» Give oral antibiotics first-line if

the patient is able to tolerate oral
medications, and if the severity of the
exacerbation does not require intravenous
antibiotics. [1] [95] #
• If a patient is started on intravenous

antibiotics, review them by 48 hours and
consider stepping down to oral therapy
where possible.[95]
• NICE recommends amoxicillin,
doxycycline, or clarithromycin as suitable
first-line oral options. Alternative oral
options include amoxicillin/clavulanate,
levofloxacin, and trimethoprim/
sulfamethoxazole. Suitable first-line
intravenous options include amoxicillin,
amoxicillin/clavulanate, clarithromycin,
trimethoprim/sulfamethoxazole, or
piperacillin/tazobactam.[95]
• It is worth noting that you must not
prescribe fluoroquinolones (e.g.,
levofloxacin) for mild to moderate acute
exacerbation of COPD unless other
antibiotics are considered inappropriate.
This is due to reports of disabling, long-
lasting, or potentially irreversible adverse
reactions affecting the musculoskeletal
and nervous systems.[130] [139] Avoid
fluoroquinolones in patients who have
previously had serious adverse effects
with a fluoroquinolone antibiotic. Avoid use
of a corticosteroid with a fluoroquinolone,
because co-administration could
exacerbate fluoroquinolone-induced
tendinitis and tendon rupture.[130]
» Look for improvements in dyspnoea and
sputum purulence to measure success of
antibiotic treatment. [1]
MANAGEMENT
» Additional considerations in the

community:
disease Management
Acute
• Give the patient/their family specific
advice about when to seek further
medical help, in particular: [95]
• If symptoms worsen rapidly or

significantly
• If symptoms do not start to
improve within an agreed time
(e.g., 2-3 days if taking antibiotics)
• If the patient becomes
systemically very unwell .
• Give advice on possible adverse
effects of antibiotics (particularly
diarrhoea). [95]
• Explain that their respiratory
symptoms may not be fully resolved
when the course has been completed.[95]
• Reassess the patient if their
symptoms worsen rapidly or
significantly. In particular:
• Beware symptoms and signs of:
• Pneumonia
• Cardiorespiratory failure
• Sepsis .
• Refer the patient to hospital if
you suspect a more serious illness
(e.g., sepsis or cardiorespiratory
failure).
• Consider antibiotic-resistant
bacteria and send a sputum sample
for microscopy, culture, and Gram
stain if symptoms have not improved
following antibiotic treatment and
these tests have not been done
already. [95]
• Only request sputum microscopy,

culture, and Gram stain in severe
disease and if hospitalisation is
being considered. This is not a
routine investigation in primary
care .[88]
• Seek specialist advice for patients:[95]
• Whose symptoms do not

improve after repeated courses of
MANAGEMENT
antibiotics
• Who have bacteria that are
resistant to oral antibiotics
• Who cannot take oral
medications .
73
disease Management
Acute
• Other options may be to give
intravenous antibiotics at
home or in the community,
rather than in hospital, where
appropriate.
• Some patients will keep antibiotics

at home for use in an exacerbation as
part of their existing action plan.
Evidence: Efficacy of antibiotics[140]
Antibiotics offer a large and consistent

beneficial effect across outcomes of patients
admitted to an intensive care unit (ICU), but
for inpatients and outpatients the effects are
inconsistent.
A Cochrane review of 19 trials with 2663

participants looked at the effects of
antibiotics in the management of acute
COPD exacerbations on:
• Treatment failure (observed 7

days to 1 month after treatment
initiation)
• Mortality
• Adverse events
• Length of hospital stay.
In the study:
• Three groups of patients were

considered:
• Outpatients (mild to moderate

exacerbation)
• Inpatients (severe exacerbation)
• ICU patients (very severe
exacerbation)
• In outpatients, there was low-
quality evidence that antibiotics
do significantly reduce the risk for
treatment failure between 7 days and
1 month after treatment initiation (RR
0.72, 95% CI 0.56 to 0.94).
• In inpatients (excluding ICU),
MANAGEMENT
moderate-quality evidence does not

show that antibiotics significantly
reduce the risk of treatment failure in
disease Management
Acute
inpatients with severe exacerbations
(RR 0.65, 95% CI 0.38 to 1.12).
• In ICU patients:
• A trial of 93 patients showed a

large and statistically significant
effect of antibiotics on treatment
failure (RR 0.19, 95% CI 0.08 to
0.45).
• Antibiotics significantly reduced
length of hospital stay (mean
difference ‐9.60 days, 95% CI ‐
12.84 to ‐6.36 days).
• Length of hospital stay (in days) was
similar in the antibiotics and placebo
groups for inpatients.
• The authors conclude that there is a
beneficial effect across outcomes of
patients admitted to an ICU, but that for
inpatients and outpatients the effects of
antibiotics are inconsistent.[140]
Evidence: Choice of antibiotic
Choose an antibiotic regimen based on local

resistance patterns, any previous culture
results for the individual patient [1] and local
antibiotic guidelines.
A review of 19 randomised controlled

trials (RCTs) found that macrolides,
fluoroquinolones, and amoxicillin/
clavulanate may be considered
equivalent for the treatment of patients
with an acute bacterial exacerbation
of chronic bronchitis in short-term
effectiveness. [141] #
• Treatment success was lower

for macrolides compared with
fluoroquinolones (OR 0.47, 95% CI
0.31 to 0.69).
• Fewer fluoroquinolone recipients
experienced a recurrence of acute
exacerbation after resolution of
MANAGEMENT
the initial episode, compared with

macrolide recipients, during the 26-
week period following therapy.
75
disease Management
Acute
• Amoxicillin/clavulanate was associated
with more adverse effects (mainly
diarrhoea) than fluoroquinolones (OR
1.36, 95% CI 1.01 to 1.85).
An analysis of five RCTs involving
287 patients found that there were no
differences between patients with acute
exacerbation of chronic bronchitis
receiving semisynthetic penicillins
(e.g., amoxicillin, ampicillin) and those
receiving trimethoprim-based regimens
(e.g., trimethoprim, trimethoprim/
sulfamethoxa zole, trimethoprim/
sulfadia zine) in: [142] #
• Treatment success (intention-to-treat

patients: n = 26; OR 1.68, 95% CI 0.91
to 3.09; clinically evaluable patients: n
= 246; OR 1.59, 95% CI 0.79 to 3.20).
• Number of drug-related adverse events
in general (n = 186 patients; OR 0.37,
95% CI 0.11 to 1.24).
consider supplemental treatment

» Monitor fluid balance.
• This may be particularly important in

patients with comorbidities, such as heart
failure.
» Depending on the patient’s clinical condition,
you may need to:[1] #
• Treat any comorbidities
• Comorbidities, such as lung

cancer, cardiovascular disease,
osteoporosis, and depression, are
common in patients with COPD
• Consider any other drugs the
patient is taking
• Administer prophylaxis against
MANAGEMENT
thromboembolism, if needed
• Give nutritional supplements
disease Management
Acute
• Patients with COPD who are
undernourished are at an increased
risk of exacerbations.
MANAGEMENT
77
disease Management
Ongoing
after stabilisation
1st monitor recovery and plan discharge
» Regularly assess symptoms and observe

the patient’s functional status. [88]
• Use intermit tent arterial blood gas

(ABG) measurements to monitor the
recovery of people with respiratory
failure who are hypercapnic or
acidotic , until they are stable with a
normalised pH.[88]
• Use pulse oximetry to monitor
the recovery of people with non-
hypercapnic, non-acidotic
respiratory failure .[88]
• Do not use daily monitoring of
peak expiratory flow or FEV 1 to
monitor recovery from an exacerbation,
because the magnitude of change is
small compared with the variability of the
measurement.[88]
Practical tip
Change drug delivery from a nebuliser to

an MDI once the patient has stabilised.
This may allow an earlier discharge from
hospital.
» You (along with the patient and family)

should be confident that the patient can
manage their symptoms at home before
they are discharged.
• If the patient smokes, reinforce

the advice to the patient that they
must stop smoking and provide
information on how to access the
services that help with this. [144] #
• Offer a 'harm reduction'

approach, such as reducing the
number of cigaret tes smoked
or temporary abstinence . This
may be a practical step for patients
struggling to quit.[145]
• Review the patient’s long-term
medication.
MANAGEMENT
• Re-establish people on their

optimal maintenance
bronchodilator therapy before
discharge.[88]
disease Management
Ongoing
• Provide vitamin D supplementation, if
required. Supplementation of patients with
severe deficiency results in a reduction in
exacerbations and hospitalisation.[1]
• Consider a hospital-at-home or
assisted discharge scheme, where
available, once the patient is stable.
[88] [146] [147]
• The decision over which patients

are suitable for such schemes
will need a team approach,
as will the implementation of
such schemes. Take patient
factors and preferences into
account.[88] Consider using
a validated prognostic score,
such as the DECAF (Dyspnoea,
Eosinopenia, Consolidation,
Acidaemia, and atrial Fibrillation)
score, to determine which patients
are suitable for this approach.[146]
• Refer for a pulmonary rehabilitation
programme, as required, to improve
exercise tolerance, physical ability,
and quality of life. [148] #
• Pulmonary rehabilitation is a
multidisciplinary programme
of care that involves physical
rehabilitation as well as guidance
on disease management,
nutrition, and other lifestyle
issues (e.g., smoking cessation,
medicine compliance and inhaler
technique, supplemental oxygen,
and maintenance of physical
activity).[149]
» Prior to discharge: [1] [88]
• Review all clinical data and test

results : identify and manage any
abnormalities.
• Measure (or review previous) spirometry
in all patients.[91]
• Ensure satisfactory oximetry or ABG
results in patients who have had an
episode of respiratory failure.
• Assess the need for continuing ox ygen
therapy .
MANAGEMENT
• Check the patient’s understanding

of the withdrawal of their acute
medications and their re-established
maintenance therapy .
79
disease Management
Ongoing
• Give appropriate information on the
correct use of medications and oxygen.
• Reassess inhaler technique .
• Provide a management plan for
comorbidities .
• Make arrangements for follow-up and
home care .
Practical tip
Although there are insufficient data

that specific 'care bundles' at hospital
discharge reduce readmission
rates, improve mortality, or are cost-
effective,[1] the general principles are all
worth considering as part of discharge and
follow-up:
• Education
• Optimisation of medication
• Supervision and correction of inhaler
technique
• Assessment and management of
comorbidities
• Early rehabilitation
• Telemonitoring
• Continuing patient contact.
Evidence: Pulmonary
rehabilitation[148]
Pulmonary rehabilitation was found to be

a safe intervention to improve quality of life
and exercise capacity for patients with COPD
after an exacerbation.
A Cochrane review looked at 20 studies

involving 1477 participants with COPD
to assess the impact of pulmonary
rehabilitation after an exacerbation of
COPD versus usual care.
• Quality of life was measured using

questionnaires and exercise capacity
was measured using walking tests,
such as the 6-minute walk test.
• Eight studies that used the St George’s
Respiratory Questionnaire reported a
MANAGEMENT
statistically significant effect on total

score.
• Thirteen studies involving 819
participants used the 6-minute walk
disease Management
Ongoing
test. The 6-minute walk distance
improved, on average, by 62 metres
(95% CI 38 to 86).
• Six studies including 670 participants
contributed data on mortality. The
quality of evidence was low. Meta‐
analysis showed no statistically
significant effects of rehabilitation on
mortality (pooled OR 0.68, 95% CI
0.28 to 1.67).
• Eight studies involving 810 participants
contributed data on hospital
readmissions. Moderate‐quality
evidence showed that pulmonary
rehabilitation reduced hospital
readmission (pooled OR 0.44, 95%
CI 0.21 to 0.91). However, of the
eight studies, four showed large and
statistically significant reductions in the
risk of hospital admission associated
with pulmonary rehabilitation, and four
showed no effect.
Primary prevention
Multiple factors impact the risk of subsequent exacerbations and these vary among individual patients.
Following COPD exacerbation, every effort should be made to both identify and mitigate potentially
modifiable factors to reduce the risk of subsequent exacerbation events.
Previous exacerbation history is a key risk factor for future exacerbations.[1] [55] People with a high burden
of symptoms and history of frequent exacerbations are at particular risk of future exacerbations and
mortality.[1] [80]
Offer smoking cessation advice and treatment to all people with COPD who smoke.[81] Smoking cessation
can reduce the risk of exacerbations in people with COPD.[82] See our topic Smoking cessation .
Advise all patients to avoid other potential triggers such as wood smoke, dust, and other airborne pollutants.
A primary goal of treating stable COPD is to reduce symptoms and future risk of exacerbations.[1]
Vaccinations can reduce the chance of COPD exacerbations; specifically consider the following.
• Pneumonia: in the UK, all patients with COPD should receive pneumococcal immunisation with a
MANAGEMENT
single dose of PPV23.[83] Outside of the UK, many countries follow recommendations from the Global
Initiative for Chronic Obstructive Lung Disease (GOLD) that all patients >65 years of age should
receive PCV13 and PPSV23. The PPSV23 is also recommended by GOLD for younger COPD patients
with significant comorbid conditions including chronic heart or lung disease.[1]
81
disease Management
• Evidence from a Cochrane review showed that pneumococcal vaccination in people with COPD
reduced the chance of an acute exacerbation (and additionally provided some protection against
community-acquired pneumonia).[84]
• Influenza: all patients with COPD should be vaccinated against influenza virus to reduce COPD
exacerbations.[1] [85]
• Evidence from randomised controlled trials showed that inactivated influenza vaccination had
a clinically important and significant effect on influenza‐related exacerbations, and probably an
effect on the total number of exacerbations, in people with COPD.[86]
• Tetanus/diphtheria/pertussis: GOLD endorses the recommendation from the US Centers for Disease
Control and Prevention that all patients with COPD who have not been vaccinated against tetanus/
diphtheria/pertussis in adolescence should receive the Tdap vaccine.[1] However, bear in mind that
this is not a current recommendation in some countries, including the UK.
Consider also prophylactic pharmacotherapy.
• Consider using mucolytic agents to decrease exacerbations in people with COPD. Mucolytic agents
may be beneficial in reducing days of disability per month and possibly hospitalisations.[87] The 2021
GOLD guideline states that treatment with mucolytic agents such as carbocisteine and acetylcysteine
may be most beneficial for patients not on inhaled corticosteroids. GOLD also states that erdosteine
may have a significant effect on (mild) exacerbations, irrespective of concurrent treatment with inhaled
corticosteroids.[1] However, bear in mind that the National Institute for Health and Care Excellence in
the UK does not recommend routinely using mucolytics to prevent exacerbations in people with stable
COPD.[88]
• A specialist team might consider prophylactic use of a macrolide antibiotic for preventing
exacerbations on an individual patient basis. Although there appears to be some benefit of using
macrolides in decreasing exacerbations, this is based on a limited number of studies, and concerns
remain about antibiotic resistance with long-term use.[89] In clinical practice, prophylactic antibiotics
are contraindicated in patients with previously isolated non‐tuberculous mycobacteria, due to the risk
of developing resistant non‐tuberculous mycobacteria.
Secondary prevention
After an exacerbation, ensure the patient understands their usual treatment regimen and assess their inhaler
technique. Discuss the importance of adhering to their routine COPD medication and explain that they may
develop worsening signs and symptoms if they don’t continue with their usual regimen as prescribed.[242] A
goal of managing stable COPD is to reduce further exacerbations.[1]
In addition, advise the patient to continue with other measures that will contribute to the prevention of further
exacerbations, such as seasonal vaccines, smoking cessation, and trigger avoidance; consider prophylactic
pharmacotherapy as appropriate. For more on this, see Primary prevention .
Provide vitamin D supplementation, if required. Supplementation of patients with severe deficiency results in
a reduction in exacerbations and hospitalisation.[1]
People with COPD tend to be less physically active than those without the condition, and low physical activity
levels are associated with a faster rate of decline in lung function and increased hospitalisations for COPD
exacerbations over time.[236] [243] [244] Encourage patients to participate in pulmonary rehabilitation
programmes, where available. Pulmonary rehabilitation is a multidisciplinary programme of care that involves
physical rehabilitation as well as guidance on disease management, nutrition, and other lifestyle issues (e.g.,
smoking cessation, medicine compliance and inhaler technique, supplemental oxygen, and maintenance of
physical activity).[149] These initiatives can improve exercise tolerance, physical ability, and quality of life,
MANAGEMENT
therefore playing an important role in the prevention of subsequent exacerbations.[148]
Consider a hospital-at-home or assisted discharge scheme, where available, once the patient
is stable .[88] [146] [147] The decision over which patients are suitable for such schemes will need a
team approach, as will the implementation of such schemes. Take patient factors and preferences into
disease Management
account.[88] Consider using a validated prognostic score, such as the DECAF score, to determine which
patients are suitable for this approach.[146]
Outpatient follow-up of patients within 30 days of hospital discharge following acute exacerbations also helps
prevent readmissions and relapse of disease.[245] Action plans can help patients recognise worsening
symptoms, initiate earlier treatment, and reduce overall impact of exacerbations.[81] [246]
Although tele-health is used in some regions for home-based disease monitoring and management
intervention,[247] it is not currently recommended for exacerbation prevention.[1] [81] Randomised controlled
trials have suggested that the use of nurse-centred tele-assistance may decrease the occurrence of
exacerbations of COPD, urgent care visits, and hospitalisation.[247] The use of such programmes may be
cost-saving.[248] Other analyses have suggested that home tele-monitoring may prolong the time free of
hospitalisations or accident and emergency department visits,[249] but the total number of hospitalisations
may not be affected and another randomised controlled trial showed no clear beneficial effects.[250]
Patient discussions
Patients with COPD often under-report symptoms of acute exacerbation.[240] Regularly ask patients at
clinic visits about escalation of symptoms; ensure they understand the difference between the expected
day-to-day variation in symptoms and symptoms heralding a COPD exacerbation. Advise patients to seek
clinical advice if they experience fever, worsening of their respiratory status beyond usual day-to-day
variation, and/or a significant increase in their production of purulent sputum.
Advise any patient with diabetes taking systemic corticosteroids for an acute exacerbation of COPD to
closely monitor their blood glucose and seek medical advice if it is outside the target range.[241]
In any patient prescribed antibiotics for an exacerbation:[95]
• Give advice about possible adverse effects of the antibiotic, particularly diarrhoea.
• Explain that symptoms may not be fully resolved when the antibiotic course has been completed.
Give the patient/their family specific advice about when to seek further medical help, in particular if:
• Symptoms worsen rapidly or significantly

• Symptoms do not start to improve within an agreed time (e.g., 2-3 days if taking antibiotics)
• The patient becomes systemically very unwell.
MANAGEMENT
83
disease Follow up
Monitoring
Monitoring
FOLLOW UP
• Follow up patients at 1 month and 3 months (according to local service provision). [1]
• At 1 month : [1]
• Review discharge therapy and the patient’s understanding of the treatment regimen
• Review the need for any long-term oxygen therapy by assessing oxygen saturation
and arterial blood gas
• Consider any new need for antibiotics or corticosteroids
• Reassess inhaler technique
• Evaluate the patient’s ability to cope in their usual environment
• Document their physical capabilities
• Document current symptoms
• Assess and manage comorbidities.
• At 3 months ensure the patient has returned to a stable clinical state: [1]
• Review symptoms
• Review the patient’s understanding of the treatment regimen
• Reassess inhaler technique
• Document their physical capabilities
• Check lung function by spirometry
• Check oxygen saturations and blood gas to assess the need for ongoing long-term
oxygen therapy
• Assess prognosis using a scoring system, such as the Body mass index, airflow
Obstruction, Dyspnoea, and Exercise (BODE) index
• Assess and manage comorbidities
• Request a CT to check for the presence of bronchiectasis or emphysema in patients
with recurrent exacerbations.
• Advise the patient to continue with other measures that will contribute to the
prevention of further exacerbations, such as seasonal vaccines, smoking cessation,
and a pulmonary rehabilitation programme. For more detailed information on prevention, see
Primary prevention .
• Some presentations of an exacerbation actually represent ongoing deterioration and disease
progression.
disease Follow up
Complications
Complications Timeframe Likelihood
FOLLOW UP
mechanical ventilation and ventilator-associated short term high
pneumonia
Patients who are ventilated are at high risk of infection. May be due to aspiration following intubation and/
or related to bypassing normal anatomical structures involved in host defense.
antibiotic-related diarrhoea short term high
Antibiotic-associated colitis, which may be due to Clostridium difficile , is a recognised complication of

exposure to antibiotics.
mechanical ventilation and ventilator-associated short term medium

barotrauma
Occurs due to mechanical ventilation, and is the development of extra-alveolar air. Careful use of
ventilator settings, including use of lower tidal volumes, faster inspiratory flow rates, and monitoring airway
pressures may help prevent the occurrence of this complication.
hypotension due to mechanical ventilation variable low
Occurs due to increased intrathoracic pressure and increased dynamic hyperinflation, leading to
decreased venous return to the heart, often in conjunction with relative volume depletion and/or use of
anxiolytic and/or narcotic medications.
Prognosis
Morbidity and mortality among people with COPD occurs most often in the context of exacerbations. A study
identified an approximately 50% 5-year mortality following hospitalisation for COPD exacerbation.[231]
Re-hospitalisation and/or mortality have been associated with lower FEV 1 , higher PaCO 2 , lower PaO 2
, lower body mass index, older age, comorbidities, and low physical activity levels.[232] [233] [234] [235]
[236] [237] [238] The multidimensional CODEX (comorbidity, obstruction, dyspnoea, previous severe
exacerbations) index can predict readmission and survival at 3 months and 1 year after hospitalisation for
COPD exacerbation.[239]
Acute exacerbations range from very mild to severe and life-threatening.
Patients who have had a significant exacerbation of COPD may not always recover back to their pre-illness
functional status. Pulmonary rehabilitation may be required to improve exercise tolerance, physical ability,
and quality of life after discharge.
85
disease Guidelines
Diagnostic guidelines
United Kingdom
Chronic obstructive pulmonary disease in over 16s: diagnosis and

management
Published by: National Institute for Health and Care Excellence Last published: 2019
International
Global strategy for the diagnosis, management, and prevention of chronic

obstructive pulmonary disease: 2021 report
Published by: Global Initiative for Chronic Obstructive Lung Disease Last published: 2021
GUIDELINES
North America
VA/DoD clinical practice guideline for the management of chronic obstructive

pulmonary disease
Published by: US Department of Veterans Affairs; US Department of Last published: 2014
Defense
Treatment guidelines
United Kingdom
Chronic obstructive pulmonary disease in over 16s: diagnosis and

management
Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial

prescribing
BTS guideline for ox ygen use in adults in healthcare and emergency set tings
Published by: British Thoracic Society Last published: 2017
BTS/ICS guideline for the ventilatory management of acute hypercapnic

respiratory failure in adults
Published by: British Thoracic Society; Intensive Care Society Last published: 2016
disease Guidelines
Europe
Guidelines for the management of adult lower respiratory tract infections

Published by: European Respiratory Society; European Society for Last published: 2011
Clinical Microbiology and Infectious Diseases
International
Global strategy for the diagnosis, management, and prevention of chronic

obstructive pulmonary disease: 2021 report
Published by: Global Initiative for Chronic Obstructive Lung Disease Last published: 2021
An official American Thoracic Society/European Respiratory Society policy

statement: enhancing implementation, use, and delivery of pulmonary
rehabilitation
GUIDELINES
Published by: American Thoracic Society; European Respiratory Last published: 2015
Society
An official American Thoracic Society/European Respiratory Society

statement: key concepts and advances in pulmonary rehabilitation
Published by: American Thoracic Society; European Respiratory Last published: 2013
Society
North America
ACR appropriateness criteria: acute respiratory illness in immunocompetent

patients
Published by: American College of Radiology Last published: 2018
Screening for chronic obstructive pulmonary disease

Published by: US Preventive Services Task Force Last published: 2016
VA/DoD clinical practice guideline for the management of chronic obstructive

pulmonary disease
Published by: US Department of Veterans Affairs; US Department of Last published: 2014
Defense
87
disease Online resources
Online resources
1. Coronavirus disease 2019 (COVID-19). (external link)
2. The AMBER care bundle (external link)

ONLINE RESOURCES
disease Evidence tables
Evidence tables
How does non#invasive ventilation (NIV) compare with usual care in people
EVIDENCE TABLES
with acute hypercapnic respiratory failure due to exacerbation of chronic
obstructive pulmonary disease?
This table is a summary of the analysis reported in a Cochrane Clinical Answer that focuses on the
above important clinical question.
View the full source Cochrane Clinical Answer
Evidence B * Confidence in the evidence is moderate or low to moderate where GRADE has
been performed and the intervention may be more effective/beneficial than the
comparison for key outcomes.
Population: People with acute hypercapnic respiratory failure due to chronic obstructive pulmonary disease
exacerbation
Intervention: NIV plus usual care
Comparison: Usual care alone (combinations of pharmacological therapies)
† ‡
Outcome Effectiveness (BMJ rating) Confidence in evidence (GRADE)
Mortality (where reported, Favours intervention Moderate

duration of follow‐up to
intensive care unit [ICU] or
hospital discharge)
Need for endotracheal Favours intervention Moderate

intubation (where reported,
duration of follow‐up 3 days
to 30 days, ICU discharge, or
hospital discharge)
Symptom scores (1 hour to 3 No statistically significant GRADE assessment not performed for
days) difference this outcome
Duration of ICU stay No statistically significant GRADE assessment not performed for
difference this outcome
Duration of hospital stay Favours intervention Moderate
Treatment intolerance Favours comparison GRADE assessment not performed for

this outcome
89
† ‡
Outcome Effectiveness (BMJ rating) Confidence in evidence (GRADE)
Partial pressure of carbon No statistically significant GRADE assessment not performed for
EVIDENCE TABLES
dioxide (PaCO2; 1 hour post‐ difference this outcome

intervention)
Partial pressure of oxygen Favours intervention GRADE assessment not performed for
(PaO2; 1 hour post‐ this outcome
intervention)
Complications of treatment: See note # GRADE assessment not performed for

NIV-related this outcome
Complications of treatment: Occurs more commonly with GRADE assessment not performed for
Non-NIV-related usual care alone compared with this outcome
NIV plus usual care (favours
intervention)
Note
# 30% of people in the NIV plus usual care group had complications specifically related to NIV (not
experienced in the usual care alone groups). See Cochrane Clinical Answer (CCA) for more details.
* Evidence levels
The Evidence level is an internal rating applied by BMJ Best Practice. See the EBM Toolkit for details.
Confidence in evidence
A - High or moderate to high

B - Moderate or low to moderate
C - Very low or low
† Effectiveness (BMJ rating)

Based on statistical significance, which demonstrates that the results are unlikely to be due to chance, but
which does not necessarily translate to a clinical significance.
‡ Grade certainty ratings
High The authors are very confident that the true

effect is similar to the estimated effect.
EVIDENCE TABLES
Moderate The authors are moderately confident that
the true effect is likely to be close to the
estimated effect.
Low The authors have limited confidence in the
effect estimate and the true effect may be
substantially different.
Very Low The authors have very little confidence in
the effect estimate and the true effect is
likely to be substantially different.
BMJ Best Practice EBM Toolkit: What is GRADE?
91
disease References
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Figure 1: Assess severity to determine where and how to treat the patient
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Acute Exacerbation of Chronic Obstructive Pulmonary Disease

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Acute Exacerbation of Chronic Obstructive Pulmonary Disease

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Acute exacerbation of

Last updated: May 26, 2021

Treatment includes bronchodilators, systemic corticosteroids, and antibiotics.

gastro-oesophageal reflux and/or swallowing dysfunction

Influenza, respiratory syncytial virus, parainfluenza, coronavirus, adenovirus, and human

• Sudden worsening of resting dyspnoea

• Exclude differential diagnoses that require immediate management, such as acute

Sputum purulence and volume

• Co-infection with viruses and bacterial pathogens is not uncommon.

• May present as prolongation of the expiratory phase of breathing on examination.

• May result from worsened airflow limitation and chest hyperinflation.[14]

1. Relevant medical history

• Spirometry-confirmed diagnosis of COPD.[91]

• Consider taking a collateral history.

• Some patients keep corticosteroids as stand-by medication at home and

Symptoms of an exacerbation usually last 7 to 10 days, though may be longer.[1]

• Check the patient’s adherence to routine COPD medication .

• Use an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach to assess

Perform a physical examination of the patient.

• Vital signs (including SaO 2 via pulse oximetry or ABG )[96]

• Pale, clammy skin

Evidence: Causes of early death in patients hospitalised with COPD exacerbation

Consider comorbidities and complications of COPD contributing to the mortality risk.

A retrospective study looked at the autopsy results of 43 patients with a hospital

• Cardiac failure (n = 16; 37.2%)

• Use diuretics to control oedema.

Severity and treatment set ting

• Some patients can manage an exacerbation themselves at home or at a community setting,

Assess severity to determine where and how to treat the patient

• Sudden worsening of resting dyspnoea

• Respiratory rate 20 to 30 breaths/minute

• Ensure that there is no evidence of hypercapnia before moving to higher

• Respiratory rate >30 breaths/minute

• Ensure that there is no evidence of hypercapnia before moving to higher

• Respiratory rate >30 breaths/minute

ABG (in hospital)#

Pulse oximetry (in hospital and in the community)

• Ensure a good pulse wave is picked up by the device.

ECG (in hospital and in the community if available)#

• Consider a myocardial infarction or pneumothorax if chest tightness or other chest

FBC with platelets (in hospital)#

Urea, electrolytes, and creatinine (in hospital)

• An abnormal result may suggest additional medical disorders.

CRP (in hospital)

• An abnormal result may suggest presence of infection.

CXR (in hospital)

Can be used to exclude differential or comorbid diagnoses, including pneumothorax,

Sputum microscopy, culture, and Gram stain (in hospital)

• Not a routine investigation in primary care.

Vitamin D (in hospital or in the community)

Respiratory virus diagnostics

• Use to identify any treatable agent.

• COPD exacerbations can lead to myocardial injury.

Serum theophylline level

Pro-brain natriuretic peptide

• May identify a pulmonary embolus, pneumonia, pleural effusion, or a malignancy.

• Higher levels of procalcitonin have been detected in severe bacterial infections.[107]

Point-of-care C-reactive protein (CRP)

• Raised levels of CRP suggest the presence of bacterial infection.

History and exam

• Document the current degree of shortness of breath and exercise tolerance.

• An increase or change in character compared with the patient’s day-to-day cough.

increased sputum purulence and volume (common)