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Characterize the symptoms: ❑ Increased cough ❑ Increased Dyspnea ❑ Increased sputum production ❑ Wheezing

Examine the patient: ❑ Pulse oximetry ❑ Arterial blood gas

Consider alternative dagnosis: ❑ Pulmonary embolism ❑ Heart failure ❑ Asthma exacerbation ❑ Bronchiectasis ❑ Broncholitis obliterans

Supplement Oxygen: (Urgent) Maintain SaO2 ≥ 88-92%

Need for ICU admission? ❑ Hemodynamic instability AND/OR ❑ Changes in mental status (confusion, lethargy, coma) AND/OR ❑ Severe dyspnea that responds inadequately to initial emergency therapy AND/OR ❑ Worsening hypoxemia (PaO2 <40 mm Hg) and/or respiratory acidosis (pH <7.25)

No

Yes

Indications for Hospitalization: ❑ Marked increase in intensity of symptoms (eg, sudden development of resting dyspnea) ❑ Presence of serious comorbidities (eg, heart failure or newly occurring arrhythmias) ❑ Failure of an exacerbation to respond to initial medical management ❑ Onset of new physical signs (eg, cyanosis, peripheral edema) ❑ Severe underlying COPD (GOLD 3—4 categories) ❑ Frequent exacerbations (≥2 events per year) ❑ Insufficient home support ❑ Older age (>65 years)

Assessment of Exacerbation: ❑ Cardinal symptoms (↑ dyspnea, ↑ sputum volume, and ↑ sputum purulence) ❑ ECG (identify coexisting cardiac problems) ❑ Chest radiograph (exclude alternative diagnoses) ❑ Whole-blood count (identify polycythemia, anemia, or leukocytosis) ❑ Electrolytes and glucose (identify electrolyte disturbances or hyperglycemia)

❑ Admit patient to ICU ❑ Classify as Life-threatening COPD exacerbation ❑ Assess patients need for mechanical ventilation

Indications for Noninvasive Mechanical Ventilation ❑ Respiratory acidosis (arterial pH < 7.35 or PaCO2 >45 mm Hg) ❑ Severe dyspnea with signs of respiratory muscle fatigue ❑ Increased work of breathing

Indications for Invasive Mechanical Ventilation ❑ Diminished consciousness, psychomotor agitation inadequately controlled by sedation ❑ Severe hemodynamic instability without response to fluids and vasoactive drugs ❑ Respiratory pauses with loss of consciousness or gasping for air ❑ Life-threatening hypoxemia in patients unable to tolerate NIV ❑ Persistent inability to remove respiratory secretions ❑ Heart rate <50/min with loss of alertness ❑ Severe ventricular arrhythmias ❑ Respiratory or cardiac arrest ❑ Failure of initial trial of NIV ❑ Massive aspiration

Mild Exacerbation (⊕ 1 cardinal symptom) ❑ Consider outpatient management ❑ Require change of inhaled treatment by the patient

Moderate Exacerbation (⊕ 2 cardinal symptoms) ❑ Consider outpatient management ❑ Require a short course of antibiotics and/or oral corticosteroids

Severe Exacerbation (⊕ 3 cardinal symptoms) ❑ Consider inpatient management ❑ Assess symptoms, ABG, and CXR ❑ Monitor fluid balance and nutrition ❑ Identify and treat associated conditions ❑ Consider subcutaneous heparin or LMWH ❑ Controlled oxygen therapy (consider NIV if indicated) ❑ Antibiotics (if ↑ sputum purulence or ⊕ bacterial infection) ❑ Corticosteroids ❑ Bronchodilators ▸ Increase doses/frequency of short-acting bronchodilators ▸ Combine short-acting β2-agonists and anticholinergics ▸ Use spacers or air-driven nebulizers