Management of Acute Exacerbation of COPD

Patient Assessment and Initial Management

The American Thoracic Society recommends obtaining arterial blood gas measurements to assess for carbon dioxide retention and respiratory acidosis in patients with acute exacerbation of COPD 1
Patients with acute exacerbation of COPD may have significant hypercapnia and respiratory acidosis despite normal oxygen saturation, indicating the need for close monitoring 1
The British Thoracic Society suggests that a pH < 7.26 predicts poor outcome and may indicate the need for ICU-level care 1
The use of accessory muscles or paradoxical breathing in patients with acute exacerbation of COPD indicates the need for non-invasive ventilation (NIV) 1
The European Respiratory Society recommends continuing nebulized bronchodilators, such as salbutamol and ipratropium bromide, every 4-6 hours in patients with acute exacerbation of COPD 2, 1
The American College of Chest Physicians suggests driving nebulizers with compressed air, rather than oxygen, if CO2 retention is present or suspected 2, 1

NIV should be initiated in patients with acute exacerbation of COPD who have persistent dyspnea at rest despite optimal medical therapy, respiratory acidosis, or a respiratory rate ≥ 25/min 1, 2
The American Thoracic Society recommends titrating oxygen carefully using a Venturi mask or nasal cannula in patients with acute exacerbation of COPD who have hypoxemia 1
The target PaO2 should be > 7.5 kPa (56 mmHg) while monitoring pH 1

The British Thoracic Society suggests considering intravenous aminophylline in patients with acute exacerbation of COPD who are not responding to initial therapy, although evidence for effectiveness is limited 1
The European Respiratory Society recommends ensuring appropriate antibiotic coverage in patients with acute exacerbation of COPD, with first-line options including amoxicillin or tetracycline 1
The American College of Chest Physicians suggests administering diuretics only if there is peripheral edema and elevated jugular venous pressure indicating cor pulmonale 1

Patients with acute exacerbation of COPD should be transferred to the ICU and considered for intubation if they have a pH < 7.26 despite NIV, exhaustion, confusion, or decreased level of consciousness, inability to tolerate or failure of NIV, or hemodynamic instability or life-threatening arrhythmias 1, 2