This document provides an overview and guidelines for the management of COPD exacerbations. It defines a COPD exacerbation and lists the main causes. Exacerbations are classified by severity from mild to very severe/life-threatening. The document outlines potential indications for hospitalization, management of severe exacerbations, and indications for intensive care, noninvasive ventilation, and invasive mechanical ventilation. Discharge criteria and recommendations for follow-up are also provided. Case studies with discussion points are included to demonstrate application of the guidelines.

1. COPD Exacerbation

2. Outline
• Definition & causes
• Differential diagnosis
• Classification of severity
• Indications for hospitalizations
• Management of severe exacerbations
• Indications for MICU admission, NIV & IMV
• Discharge criteria and recommendations for follow up

3. Definition
• An exacerbation of COPD is a sustained worsening of
the patient's condition, from the stable state and
beyond normal day-to-day variations that is acute in
onset and may warrant additional treatment in a
patient with underlying COPD.
• Exacerbations are infrequent in early COPD and are
largely a feature of moderate-to-severe disease.

4. COPD exacerbation
• Negatively affects a patient’s quality of life
• Accelerates the rate of decline of lung function
• Associated with significant mortality, particularly in
those requiring hospitalizations

5. Main Causes of COPD Exacerbations
• Bacterial and viral infections
• pollution events
• cold weather
• interruption of regular treatment

6. © 2020 Global Initiative for Chronic Obstructive Lung Disease

7. Classification of severity of COPD exacerbations
• Mild: treated with antibiotics but no systemic
corticosteroid. Absence of respiratory failure.
• Moderate: treated with parenteral corticosteroids with
or without an antibiotic. Absence of respiratory failure.
• Severe: Type 1 respiratory failure with hypoxaemia but
no carbon dioxide retention or acidosis.
• Very severe & Life-threatening: Type 2 respiratory
failure, decompensated with acidosis and carbon
dioxide retention.
© 2019 Global Initiative for Chronic Obstructive Lung Disease

8. Potential indications for hospitalization
assessment*

9. Management of severe but not life threatening
exacerbations*

10. What are the indications to add antibiotics
• Three cardinal symptoms-increase in dyspnea, sputum
volume and sputum purulence
• Signs of pneumonia
• Mechanical ventilation

11. Key points for the management of exacerbations

12. Indications for medical intensive care unit
admission*

13. Indications for Noninvasive mechanical ventilation
(NIV)

14. Indications for Invasive mechanical ventilation

15. Discharge criteria

16. Recommendations for follow up

17. Case study 4
• A 45 year old woman from rural area has noticed a mild,
occasionally productive cough for the past 3-4 months. The cough is
worse whenever she spends the day at her home while cooking where
is exposed to the smoke of the wood fire.
• She finally decides to visit you at the health center. Her husband and
she never smoked cigarette.
• The cough has been present for almost a year. She has no fever or
chills. She does admit to more shortness of breath when she walks
for long distance over the past six months.
• Physical examination was normal findings.
• Discussion points
• 1- What further questions do you want to ask ?
• 2- What differential diagnoses do you consider?
• 3-At this point, what further investigations do you think would
be appropriate?
• 4-What would be the best option to improve her symptoms and
slow progression?

18. Answers
1- What further questions do you want to ask ?
-characteristic of cough intermittent or persistent?
-cough with phlegm or productive?
-nigh sweating, fever or weight loss?
2- What differential diagnoses do you consider?
Tuberculosis
Bronchial asthma
Bronchiectasis
Lung cancer
COPD
3-At this point, what further investigations do you think would be appropriate?
Chest x ray, Sputum AFB, ESR, CBC
Lung function studies: flow meter and spirometer and response to salbutamol
4-What would be the best option to improve her symptoms and slow progression?
• Reduce exposure to Smoking (outdoor cooking)
• Behavioral change communication
• Nutrition and regular treatment of chest infection etc…
• Bronchodilator treatment
• Exercise to improve exercise tolerance and quality of life
• Home oxygen treatment and morphine depending on the advance of disease

19. We would like to thank
• Dr. Tewodros Haile, Dr Hanan Yusuf, Dr Amsalu Bekele and
Dr Rahel Argaw for preparing this powerpoint