COPD exacerbation
Formal Definition
An acute worsening of chronic obstructive pulmonary disease symptoms (chronic bronchitis and/or emphysema) beyond normal day-to-day variation, typically characterized by increased dyspnea, increased sputum volume, and increased sputum purulence (Anthonisen criteria); commonly triggered by viral or bacterial respiratory infection, environmental exposures, or medication non-adherence; classified by severity (mild — managed at home with bronchodilators, moderate — requires hospitalization, severe — requires ICU and potentially non-invasive or invasive ventilatory support).
How It's Used on the Ward
"COPD exacerbation" or "a COPD flare" — the chronic lunger comes in short of breath, often with increased sputum production and purulence; the usual triggers are viral (URI) or bacterial infections; treat aggressively with bronchodilators, steroids, and antibiotics if bacterial features present, plus support with BiPAP if respiratory failure developing.
Example
""72-year-old former smoker (60 pack-years) with known COPD on triple inhaler therapy (LABA/LAMA/ICS) and home oxygen 2L for chronic hypoxemia presents with 4 days of worsening dyspnea, increased sputum production, sputum now yellow-green. SpO2 82% on his home O2, RR 28, using accessory muscles, able to speak in short phrases only. ABG: pH 7.28, PaCO2 62 (chronic normal ~50, now acute-on-chronic respiratory acidosis). Diagnosis: severe COPD exacerbation with acute-on-chronic hypercapnic respiratory failure. Started BiPAP, IV methylprednisolone 60mg, IV ceftriaxone + azithromycin, increased bronchodilator frequency. Admitted to stepdown.""
Clinical Context
Anthonisen criteria (3 cardinal symptoms): (1) increased dyspnea, (2) increased sputum volume, (3) increased sputum purulence. Type 1 (all 3 severe) — antibiotics indicated. Type 2 (2 of 3) — antibiotics usually indicated. Type 3 (1 of 3 with fever/URI) — antibiotics controversial. Triggers: viral URI (rhinovirus, influenza most common), bacterial (H. influenzae, S. pneumoniae, Moraxella, Pseudomonas in severe disease), atypical (Mycoplasma, Chlamydia). Treatment: SABA (albuterol neb) q1-4h, SAMA (ipratropium neb) similar frequency (caution: not effective acutely), systemic steroids (prednisone 40mg daily x 5 days — REDUCE trial, or methylprednisolone 60-125mg IV for inpatients), antibiotics (azithromycin, doxycycline, amoxicillin-clavulanate for outpatient; ceftriaxone + azithromycin for inpatient; antipseudomonal if risk factors or recent hospitalization). Oxygen: target SpO2 88-92% (avoid hyperoxia — risk of CO2 retention in chronic retainers); use venturi mask for precision. BiPAP for acute or acute-on-chronic hypercapnic respiratory failure (pH <7.35 with PaCO2 elevated). Criteria for intubation: failure of BiPAP, mental status decline, severe acidosis (pH <7.25), hemodynamic instability. Discharge with inhaler optimization, pulmonary rehab referral, smoking cessation, vaccination (influenza, pneumococcal, RSV, COVID, Tdap).