- Respiratory failure: pO₂ 50 mmHg, pH <7.35
- Altered mental status
- Hemodynamic instability
Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
Must-Not-Miss / Red Flags
Patient Explanation
“Your lungs have become more inflamed than usual, making it hard to breathe. We will give you strong medicines to open your airways and fight infection.”
Board Fact
“The most common pathogens causing COPD exacerbation are Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.”
ICD-10
J44.1
Definition & Core Concept
An acute worsening of respiratory symptoms in a patient with COPD, typically triggered by respiratory infections, air pollution, or non‑compliance with maintenance therapy, necessitating additional treatment.
Epidemiology & Risk Factors
- COPD affects 10% of adults globally
- Exacerbations become more frequent as disease progresses (GOLD stages 3‑4)
- Associated with accelerated loss of lung function
Pathophysiology (Rule of 3)
- Trigger (infection/pollutant) → airway inflammation & mucus hypersecretion
- Dynamic hyperinflation → increased work of breathing, air trapping
- V/Q mismatch & respiratory muscle fatigue → hypoxemia and hypercapnia
Clinical Presentation
- Increased dyspnea, cough, sputum volume or purulence
- Use of accessory muscles, pursed‑lip breathing
- Wheezing, prolonged expiratory phase
Diagnostic Workup
ABG: assess for hypoxemia and hypercapnia. Chest X‑ray: rule out pneumonia, pneumothorax. Sputum culture if purulent.
Management Protocol
- Oxygen titrated to SpO₂ 88‑92%
- Bronchodilators: Ipratropium + Salbutamol nebulized
- Systemic corticosteroids: Prednisone 40 mg PO daily for 5‑7 days
- Antibiotics if increased sputum purulence: Amoxicillin‑clavulanate or Doxycycline
- Non‑invasive ventilation (NIV) if pH 45 mmHg
Complications & Prognosis
- Respiratory failure requiring intubation
- Pneumothorax
- Cardiac arrhythmias due to hypoxemia
ICU Criteria
ICU admission if: persistent respiratory acidosis despite NIV, hemodynamic instability, or GCS decline.
Clinical Vignette
A 68‑year‑old former smoker with known COPD presents with 3 days of increasing dyspnea, productive cough with green sputum, and wheezing. He ran out of his tiotropium inhaler last week.
Pearls & Pitfalls
- Target SpO₂ 88‑92% – excessive oxygen may suppress respiratory drive in chronic CO₂ retainers.
- Do not delay NIV in suitable patients – it reduces mortality and intubation rates.
Discharge & Follow-Up
Ensure inhaler technique, arrange pulmonary rehabilitation, and provide smoking cessation counselling.
Literature & Guidelines
GOLD 2024 Guidelines for COPD. PMID: 30830897.