Diagnostic Workup

Although AECOPD is largely a clinical diagnosis, some diagnostic modalities are useful to help rule in or rule out alternative diagnoses.^4,10,11

• Chest X-ray is used to evaluate for pneumothorax, pulmonary edema, or pneumonia.
• Ultrasound evaluates for global heart function, right heart strain, pulmonary edema, and lung sliding.
• Complete blood count evaluates for leukocytosis or anemia.
• Basic metabolic panel evaluates for electrolyte abnormalities.
• ECG evaluates for dysrhythmias, acute coronary syndrome, or signs of right heart strain.
• Viral polymerase chain reaction (PCR) can be considered in evaluating for a viral infection, such as COVID-19 or influenza.
• Clinical decision tools such as PERC +/- d-dimer or CT angiography of the chest are used if pulmonary embolism is considered likely.
• Brain natriuretic peptide can be considered to evaluate for heart failure.
• Troponin can be considered to evaluate for acute coronary syndrome.
• Blood gas (venous or arterial) can be considered to evaluate for extent of hypercapnia or in patients with decreased level of consciousness to assess for hypercapnic encephalopathy.

Management

Oxygen

• Supplemental oxygen should not be withheld despite risk of hypercapnia.⁴
  • Hypercapnia worsens with higher oxygen saturations largely because of increased shunting of blood away from well-ventilated alveoli into poorly ventilated alveoli.¹
• Titrate to oxygen saturation of 88-92 percent.^1,4,11
• Common methods of oxygen delivery:
  • Nasal cannula (1-6 L/min, about 24-45 percent FiO₂);
  • Heated high flow nasal cannula (10-60 L/min, 21-100 percent FiO₂);
  • Simple mask (6-10 L/min, 35-50 percent FiO₂);
  • Venturi mask (2-15 L/min, 24-60 percent FiO₂); and
  • Non-rebreather (10-15 L/min, about 80 percent FiO₂).⁸

Bronchodilators

• Albuterol 2.5-5 mg plus ipratropium 0.5 mg every 30 minutes x3 doses;
• No significant difference in FEV1 improvement between metered dose inhalers (MDI) and air-driven nebulizers; and
• Can be administered in-line through high-flow nasal cannula or BPAP. ^4,10,11,12

Corticosteroids

• Systemic corticosteroids shorten recovery time and improve FEV1, oxygenation, risk of early relapse, treatment failure, and length of hospitalization.^4,14
• Oral prednisone 40-60 mg (or equivalent) daily for five days.^4,11
• Oral corticosteroids are as effective as intravenous steroids, but a one-time dose of intravenous methylprednisolone 125 mg in the ED is useful for patients who obviously cannot tolerate oral medications.^4,6,11

Antibiotics

Antibiotic use for AECOPD patients remains a contentious topic; however, data suggests AECOPD patients requiring admission, particularly to the ICU, should receive antibiotics.^10,12 It’s important to note that there is still no consensus on which discharged AECOPD patients require antibiotics and which antibiotics are the most effective; however, limited data suggests outpatient antibiotics reduce risk of treatment failure, shorten recovery time and hospitalization duration, and increase time between exacerbations.^4,14 GOLD guidelines recommend antibiotics in patients with three of the cardinal symptoms (increased dyspnea, sputum volume, and purulent sputum), or purulent sputum plus another of the cardinal symptoms, or in those requiring mechanical ventilation (invasive or noninvasive). While the American Thoracic Society (ATS) agrees that purulent sputum is associated with the need for antibiotics, ATS also suggests considering disease severity when deciding which discharged AECOPD patient gets antibiotics.¹⁴ Overall, those with non-severe baseline COPD, no significant comorbidities, minor AECOPD symptoms, and no purulent sputum can likely be discharged without antibiotics.^4,7,10,14 There is also emerging data evaluating C-reactive proteins (CRP) cutoffs as a potential guide for antibiotic prescription.⁷