Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Managing Acute Exacerbations of Chronic Obstructive Pulmonary Disease

  An acute exacerbation of chronic obstructive pulmonary disease (COPD) is a sustained worsening of breathlessness, cough, sputum volume, or sputum purulence that requires a change in treatment. It can develop over hours or days and may quickly lead to respiratory failure, especially in people with advanced airflow limitation or significant cardiovascular disease.

  Effective care begins with rapid assessment rather than assuming every episode is a routine flare-up. Pneumonia, pulmonary embolism, heart failure, arrhythmia, pneumothorax, and acute coronary syndrome can produce similar symptoms. A structured approach helps clinicians identify the cause, grade severity, and select the safest treatment setting.

  Respiratory medicine congresses such as those associated with APSR and KATRD provide an important forum for discussing practical COPD management, from emergency stabilization to discharge planning. The same principles apply across emergency departments, inpatient wards, primary care clinics, and home-based services.

  Recognizing A Serious Exacerbation

  The initial assessment should establish the patient’s baseline exercise tolerance, usual oxygen saturation, home oxygen use, previous intensive care admissions, and current maintenance therapy. Ask about symptom onset, infectious contacts, medication access, inhaler use, smoking exposure, and recent hospitalizations. A change in mental status, exhaustion, cyanosis, or inability to speak in full sentences signals potential respiratory compromise.

  Vital signs, work of breathing, chest examination, and pulse oximetry are essential. Blood gas analysis is particularly important when there is severe dyspnea, drowsiness, suspected carbon dioxide retention, or a low oxygen saturation that does not respond as expected. Chest radiography, electrocardiography, blood tests, and viral testing should be guided by clinical findings rather than ordered mechanically.

  A patient may require hospital admission when symptoms are severe, home support is inadequate, oral intake is poor, or there is a serious comorbidity. Immediate critical care input is appropriate for worsening acidosis, hemodynamic instability, refractory hypoxemia, or declining consciousness.

  Stabilizing Breathing And Gas Exchange

  Controlled oxygen therapy is preferable to indiscriminate high-flow oxygen in patients at risk of hypercapnic respiratory failure. A commonly used target saturation is 88–92%, adjusted according to blood gas results and the individual treatment plan. Oxygen should be titrated and reassessed, since excessive oxygen administration can worsen carbon dioxide retention in susceptible patients.

  Short-acting bronchodilators are the foundation of initial pharmacological treatment. A short-acting beta-2 agonist, with or without a short-acting muscarinic antagonist, can be delivered by a metered-dose inhaler with a spacer or by nebulizer. The delivery method should reflect the patient’s coordination, severity of distress, and infection-control requirements.

  Noninvasive ventilation can improve ventilation and reduce the need for intubation in selected patients with acute hypercapnic respiratory acidosis. It requires close monitoring, an experienced team, and a patient who can protect the airway and cooperate with the mask. Invasive ventilation may be necessary when noninvasive support fails or when airway protection and circulation become compromised.

  Choosing Medicines With Purpose

  Systemic corticosteroids can shorten recovery, improve lung function, and reduce treatment failure when used for an appropriate duration. A short course is generally favored, with the dose and route determined by local guidelines, severity, gastrointestinal absorption, and comorbid conditions. Clinicians should monitor glucose, mental status, fluid balance, and infection-related complications.

  Antibiotics are most useful when bacterial infection is plausible, such as increased sputum purulence accompanied by increased dyspnea or sputum volume, or when the patient requires ventilatory support. The choice should reflect local resistance patterns, allergy history, prior microbiology, renal function, and the likelihood of pneumonia. Antibiotics should not be prescribed automatically for every increase in breathlessness.

  Methylxanthines are generally avoided because their benefits are limited and adverse effects can be substantial. Sedatives and respiratory depressants also require particular caution. Every medicine should be reviewed for interactions, duplication, and the potential to worsen ventilation or falls risk.

  Clinical priority	Practical action	Reassessment
  Breathing difficulty	Give controlled oxygen and short-acting bronchodilators	Work of breathing, saturation, heart rate
  Suspected hypercapnia	Obtain blood gases and consider noninvasive ventilation	pH, carbon dioxide, mental status
  Possible infection	Evaluate sputum change, fever, imaging, and biomarkers where appropriate	Clinical response and culture results
  Severe deterioration	Escalate to critical care and prepare for advanced airway support	Hemodynamics, fatigue, ventilation
  Recovery planning	Reconcile medicines and confirm technique and support	Inhaler use, mobility, follow-up

  Avoiding Treatment Delivery Errors

  Inhaler technique frequently determines whether maintenance therapy reaches the lungs. During and after an exacerbation, observe the patient using each device rather than relying on verbal reassurance. Check inspiratory flow, hand-breath coordination, breath-hold time, loading steps, and cleaning practices. A spacer may improve delivery from a pressurized metered-dose inhaler.

  Education should be individualized because dexterity, vision, cognition, and inspiratory capacity vary widely. The guidance on optimizing inhaler technique is framed around asthma, yet many of its practical principles also support effective inhaler education for people with COPD.

  Nebulizers may be useful during severe distress, but they are not automatically superior to inhalers with spacers. Staff should use appropriate personal protective equipment and ventilation procedures when aerosol-generating treatments are a concern. Once the patient improves, transitioning back to a familiar portable device can simplify discharge.

  Supporting Recovery In Hospital And At Home

  Early mobilization, nutritional assessment, hydration, and venous thromboembolism prevention should be integrated into inpatient care. Review smoking status and offer evidence-based cessation support. Pulmonary rehabilitation referral is valuable after recovery, particularly for patients with reduced exercise capacity or repeated admissions.

  Before discharge, confirm that symptoms have stabilized, oxygen requirements are understood, and the patient or caregiver can use every prescribed device. Provide a written action plan explaining how to recognize worsening breathlessness, changes in sputum, fever, or reduced function. Follow-up should address medication adherence, vaccinations, comorbidities, mood, and access to clinical support.

  Long-term prevention depends on optimizing maintenance bronchodilation and identifying why the exacerbation occurred. Repeated episodes may indicate persistent exposure, poor adherence, incorrect technique, untreated sleep-disordered breathing, bronchiectasis, cardiac disease, or an unsuitable treatment regimen.

  Reducing Future Flare-Ups

  A prevention strategy should be specific rather than limited to a general instruction to “take medicines regularly.” Clinicians can use the following measures to reduce recurrence and improve self-management:

  • Demonstrate and reassess inhaler technique at every meaningful clinical review.
  • Encourage smoking cessation and reduce exposure to occupational or household pollutants.
  • Keep vaccinations current, including seasonal influenza and other recommended respiratory vaccines.
  • Offer pulmonary rehabilitation after recovery when exercise limitation persists.
  • Create an individualized action plan with clear instructions for urgent assessment.
  • Review exacerbation history before escalating or simplifying maintenance therapy.

  Patients with frequent exacerbations may benefit from specialist review to evaluate eosinophilic inflammation, chronic bronchitis, bronchiectasis, cardiac disease, and adherence barriers. Shared decisions should consider symptom burden, exacerbation risk, device preference, side effects, and the person’s ability to manage a complex regimen.

  Acute COPD care is safest when emergency stabilization, diagnostic reasoning, medication stewardship, and long-term prevention are treated as one continuum. Healthcare teams can use congress education, local protocols, and multidisciplinary review to strengthen each stage of that pathway. Visit APSR 2022 resources to engage with respiratory medicine perspectives and carry evidence-informed COPD care into daily clinical practice.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)