COPD Exacerbation

Consider a COPD exacerbation in a patient with known or likely COPD (e.g., long-term cigarette use, or coming from the developing world with long-term biofuel exposure while cooking) who has an acute worsening of dyspnea, cough, or sputum production.

The Management of COPD

  • Try to figure out what caused the exacerbation

    (viral infection or bacterial pneumonia, smoke in the air from wildfires, etc.). If the patient smokes, advise them to stop.

  • Corticosteroids

    40mg of prednisone daily for 5 days is standard. Sometimes critically ill patients receive a dose of 125mg IV methylprednisolone as their first dose of steroids.

  • Inhaled bronchodilators

    A standard regimen would be "duonebs" (ipratropium and albuterol) four times daily with extra albuterol q2h PRN. The logic here is that ipratropium lasts about 6 hours, and albuterol lasts about 2 hours. For critically ill people, sometimes duonebs q4h is prescribed.

  • Antibiotics

    If they need antibiotics for pneumonia, these will be sufficient. Otherwise, a standard regimen is 5 days of azithromycin or doxycycline. Independent of killing bacteria, azithromycin may have additional anti-inflammatory effects.

  • If the patient has acute hypercarbia,

    (as evidenced by elevated CO2 and a low pH on their blood gas), start them on BiPAP.

  • If they have hypoxemic respiratory failure without hypercarbia,

    start them on supplemental oxygen.

  • In severe cases,

    sometimes patients need to be intubated (for example, if they have worsening severe acidemia and hypercarbia despite BiPAP).

Do NOT over-oxygenate these patients, especially those with chronic CO2 retention. Goal O2 can be somewhere around 88–94%.

Image credit: Eric Tanenbaum.

Page Last Updated: September 18, 2024

Table of Contents
Headshot of Eric Tanenbaum, MD · Assistant Professor, WSU College of Medicine; Nocturnist, Swedish Hospital Medicine
Eric Tanenbaum
MD · Assistant Professor, WSU College of Medicine; Nocturnist, Swedish Hospital Medicine
envelope icon