What is the full management for Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report 2025?

Management of Acute Exacerbation of COPD (AECOPD) According to GOLD 2025

The management of AECOPD requires a systematic approach including bronchodilators, corticosteroids, antibiotics when indicated, and appropriate respiratory support, with severity assessment determining the treatment setting and intensity. 1

Initial Assessment and Classification

• AECOPD is defined as an acute worsening of respiratory symptoms that results in additional therapy 2
• Exacerbations are classified as:
  • Mild: treated with short-acting bronchodilators only
  • Moderate: treated with short-acting bronchodilators plus antibiotics and/or oral corticosteroids
  • Severe: requires hospitalization or emergency room visit, may be associated with acute respiratory failure 2
• Assess for key symptoms: increased dyspnea, increased sputum purulence/volume, increased cough and wheeze 2
• Rule out differential diagnoses: acute coronary syndrome, heart failure, pulmonary embolism, pneumonia 2, 1

Treatment Based on Severity

Mild Exacerbations (Home Management)

• Increase dose/frequency of short-acting inhaled β2-agonists, with or without short-acting anticholinergics 2, 1
• Monitor for clinical improvement or deterioration 1

Moderate Exacerbations

• Short-acting bronchodilators: increase frequency/dose of β2-agonists and/or anticholinergics 2
• Systemic corticosteroids: prednisolone 30-40mg daily for 5-7 days 2, 1
• Antibiotics if signs of bacterial infection (increased sputum purulence) 2, 1

Severe Exacerbations (Hospital Management)

• Controlled oxygen therapy: maintain SaO2 88-92% 2, 1
• Bronchodilators:
  • Short-acting β2-agonists with or without short-acting anticholinergics via nebulizer or MDI with spacer 2
  • Continue nebulized bronchodilators for 24-48 hours until clinical improvement 1
• Systemic corticosteroids:
  • Oral or IV prednisolone 30-40mg daily for 5-7 days 2
  • Improves lung function, oxygenation, and shortens recovery and hospitalization time 2
• Antibiotics:
  • Indicated for purulent sputum or signs of bacterial infection 2
  • Shortens recovery time and reduces risk of early relapse, treatment failure, and hospitalization duration 2
• Respiratory support:
  • Non-invasive ventilation (NIV) should be first-line for acute respiratory failure 2
  • Indicated for respiratory acidosis (pH <7.35) with hypercapnia (PaCO2 >45 mmHg) 2, 1
  • Mechanical ventilation if NIV fails or contraindicated 2
• Avoid methylxanthines due to side effects 2

Discharge Planning and Follow-up

• Transition to maintenance therapy with long-acting bronchodilators before discharge 2, 1
• Measure FEV1 before discharge to establish new baseline 1
• Check arterial blood gases on room air before discharge in patients who presented with respiratory failure 1
• Initiate appropriate measures for exacerbation prevention 2
• Schedule follow-up visit within 1-4 weeks to assess:
  • Symptoms and exacerbation status
  • Inhaler technique
  • Need for long-term oxygen therapy
  • Lung function (spirometry) 2

Prevention of Future Exacerbations

• Optimize maintenance bronchodilator therapy 2
• Consider adding inhaled corticosteroids for patients with history of exacerbations 2
• Ensure influenza and pneumococcal vaccinations are up to date 2
• Pulmonary rehabilitation after exacerbation 2
• Smoking cessation counseling and support 2

Common Pitfalls to Avoid

• Delaying hospital evaluation when severity is uncertain 1
• Using sedatives that can worsen respiratory depression 1
• Failing to differentiate AECOPD from other conditions with similar presentations 1
• Overuse of antibiotics when not indicated 2
• Prolonged use of systemic corticosteroids beyond recommended duration 2
• Delaying NIV in appropriate candidates with respiratory failure 2