Exacerbated COPD

Acute exacerbated COPD often remains undetected or its severity is underestimated. A sudden worsening of symptoms can be life-threatening.

COPD is the third most common cause of death worldwide. In Germany, around 6.8 million people are affected – a figure that could rise to 7.9 million by 2030. Many patients experience at least one exacerbation during the course of the disease.¹

Rapid and targeted treatment is essential to prevent respiratory acidosis, acute respiratory distress, hypoxemia or ventilatory insufficiency and to stabilize lung function.

In this article, you will learn which symptoms indicate an exacerbation of COPD, how severe it can be and which emergency measures can help.

Definition: acute exacerbated COPD

Acute exacerbated COPD (AECOPD) is defined as a significant worsening of the chronic respiratory disease that lasts for at least 2 days.²

These episodes often occur suddenly and can become life-threatening as the shortness of breath increases dramatically. They are often accompanied by increased mucus production, increased coughing and further impairment of lung function.

In this phase, intensive emergency treatment must be given to alleviate the symptoms, slow down the progression of the disease and prevent complications such as respiratory insufficiency or cardiovascular problems.

Symptoms and signs of acute exacerbation

Many COPD patients suffer chronically from dyspnea, which worsens during an exacerbation. This increased respiratory distress overloads the respiratory muscles and leads to ventilatory insufficiency. This can lead to a dangerous accumulation of carbon dioxide in the blood (hypercapnia). 

Another typical sign of acute exacerbated COPD is an increased respiratory rate of more than 20 breaths per minute, often accompanied by increased use of the auxiliary respiratory muscles.

The increased inflammation of the airways usually causes increased bronchoconstriction and higher mucus production.

In addition, other signs of acute deterioration can often be detected during a physical examination:

Medical staff must recognize the symptoms at an early stage in order to initiate targeted measures quickly. This is because the earlier an exacerbation is treated, the better the chances of avoiding serious complications.

It is particularly important to distinguish the exacerbation from other diseases with similar symptoms, such as heart failure, pneumonia or a pulmonary embolism. 

Classification by severity

According to the GOLD Report 2024 (Global Initiative for Chronic Obstructive Lung Disease) the diagnosis of exacerbation is mainly based on clinical symptoms. 

An exacerbation occurs when symptoms such as shortness of breath (dyspnea), coughing or increased sputum production worsen considerably over a period of 14 days and are often accompanied by rapid breathing (tachypnea) or an increased heart rate (tachycardia).

The severity of an exacerbation can be assessed on the basis of 5 measurable parameters: 

1. Respiratory rate
2. Heart rate
3. Oxygen saturation
4. Dyspnea intensity (measured with a visual analog scale)
5. CRP value (C-reactive protein as an inflammation marker)

Mild exacerbations often require only minor interventions. In moderate and severe episodes, however, more intensive treatment is necessary, especially if these are associated with an oxygen deficiency or CO₂ retention.

Causes of exacerbated COPD

Many factors can trigger an exacerbation of COPD, although viral or bacterial respiratory infections are often the main cause. Especially in the winter months, when colds and flu occur more frequently, the risk of a deterioration in lung function increases.

Air pollution is another major trigger. Pollutants such as particulate matter, smoke or smog irritate the already sensitive airways and can cause inflammation. Cold or dry air can also exacerbate the symptoms.

Drugs with a respiratory depressant effect such as sedatives or opioids can slow respiration. Thoracic injuries or inhalation of foreign bodies can impair respiratory function and trigger an exacerbation.

In addition, comorbidities such as heart failure, cardiac arrhythmia and pulmonary diseases such as pneumothorax or pulmonary embolism can further worsen COPD. These clinical conditions further impair lung function and promote the development of an exacerbation.

Issues such as stress or physical overload and inadequate medication are also risk factors.

Preventing an acute exacerbation of COPD

Each exacerbation can further worsen lung function. Consistent medication is therefore essential to stabilize the airways. 

The regular use of bronchodilator and anti-inflammatory inhalations is particularly important in order to alleviate symptoms and maintain lung function.

After an exacerbation, COPD patients often tend to be inactive, which increases the risk of a progressive decline in lung function. Lung sports groups and targeted rehabilitation programs are recommended after hospital stays. They increase resilience and reduce the risk of death.

Treating exacerbated COPD – emergency treatment

In most cases of acute exacerbated COPD, treatment initially consists of conservative measures to stabilize respiration and prevent deterioration. 

Bronchodilators such as beta-2 agonists (e.g. salbutamol) and anticholinergics relax the airways and make respiration easier. Corticosteroids have an anti-inflammatory effect and alleviate the symptoms. If a bacterial infection is suspected, antibiotic treatment may be necessary.

Oxygen treatment 

Controlled oxygen administration helps to prevent hypoxia and stabilize the oxygen supply. The oxygen flow must be precisely dosed, as too high a dose can impair the natural respiratory drive. 

Patients with COPD adapt to a reduced oxygen supply. Excessive oxygen administration can therefore slow down respiration and promote hypercapnia.

Hypercapnia leads to an accumulation of carbon dioxide in the blood, which can cause serious complications such as respiratory acidosis and respiratory arrest and, in the worst case, can be life-threatening. In the emergency treatment of exacerbated COPD, non-invasive ventilation is therefore often a better treatment alternative than pure oxygen therapy. 

Non-invasive ventilation

According to the ERS/ATS clinical practice guidelines, non-invasive ventilation (NIV) is strongly recommended, especially in cases of acute or chronic respiratory acidosis due to COPD exacerbation. It improves ventilation, reduces the work of respiration and can avoid more invasive measures such as intubation. However, it is also used in cases of acute respiratory insufficiency (ARI) – whether hypoxemic or hypercapnic – provided there are no absolute contraindications such as gasping or lack of spontaneous breathing.³

Typical signs of ARI are a respiratory rate above 25/min and insufficient oxygen saturation (SpO₂ < 90 %) despite oxygen administration. Ventilatory exhaustion with shallow, rapid breathing – for example in acute exacerbations of COPD or bronchial asthma – is also an argument for the use of NIV.

Treatment should begin in a semi-sitting or sitting position. In the initial phase, the main aim is to achieve good synchronization between the patient and the ventilator. If necessary, careful sedation with low-dose benzodiazepines, opiates or propofol can help to reduce anxiety or agitation – but always with caution.

Important success criteria for NIV are a decrease in dyspnea, respiratory rate and heart rate, an increase in SpO₂ and an improvement in alertness. If etCO₂ monitoring is available, a reduction in etCO₂ can also be seen as a positive sign.

If the condition worsens despite NIV, treatment must be stopped in good time and preparation made for invasive ventilation with intubation. The patient should always be ready for intubation, especially in the case of relative contraindications.

Invasive ventilation

In emergency medicine, moving to invasive ventilation is a step up from non-invasive ventilation. Intubation readiness for NIV, especially in the case of relative contraindications such as loss of consciousness, must be ensured at all times.

Ventilation with WEINMANN ventilators for acute exacerbated COPD

During an acute exacerbation of COPD, respiration often deteriorates to such an extent that medical personnel have to stabilize the oxygen levels in the blood to prevent dangerous complications such as hypercapnia. 

The MEDUMAT Standard² and MEDUVENT Standard ventilators from WEINMANN offer several non-invasive ventilation modes that provide effective support for patients in this critical phase:

• CPAP (Continuous Positive Airway Pressure): CPAP mode maintains a continuous positive pressure to prevent the air sacs from collapsing, reduce the work of respiration and alleviate respiratory distress. In acutely exacerbated COPD, this form of ventilation is often sufficient to avoid invasive ventilation and stabilize respiration.
• CPAP + ASB (Assisted Spontaneous Breathing): This mode combines CPAP with assisted spontaneous breathing. The additional pressure during inhalation makes it easier for patients to breathe and at the same time supports the removal of CO₂ from the body. This reduces the strain on the respiratory muscles and relieves the pulmonary circulation.
• BiLevel or BIPAP + ASB (Biphasic Positive Airway Pressure + Assisted Spontaneous Breathing): BiLevel offers two-phase pressure support – a higher pressure when inhaling and a lower pressure when exhaling. This form of ventilation promotes aeration of the lungs and the exhalation of CO₂. In combination with the support of spontaneous breathing, BiLevel makes work of breathing significantly easier, which is particularly important during an acute COPD exacerbation.

¹ GOLD-Report 2024: COPD-Exazerbationen verringern

² Reinhard Larsen Alexander Mathes. Beatmung Indikationen - Techniken – Krankheitsbilder, S. 527.

³ Rochwerg B et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug 31;50(2):1602426. doi: 10.1183/13993003.02426-2016. PMID: 28860265.