COPD Exacerbations: More Than Just Steroids and Nebs

A Comprehensive Approach to Acute Management and Beyond

Dr Neeraj Manikath , claude.ai

Abstract

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) represent a critical inflection point in disease progression, associated with accelerated lung function decline, increased mortality, and substantial healthcare costs. While bronchodilators and corticosteroids form the cornerstone of therapy, contemporary evidence supports a more nuanced, phenotype-driven approach. This review synthesizes current evidence on severity stratification, non-invasive ventilation strategies, antimicrobial stewardship, emerging pharmacotherapies, and the often-neglected discharge planning that determines long-term outcomes. Understanding these complexities transforms AECOPD management from a reflexive protocol into precision medicine.

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Introduction

COPD exacerbations account for over 1.5 million emergency department visits annually in the United States alone, with mortality rates approaching 10% for hospitalized patients and 25% for those requiring mechanical ventilation.[1,2] Yet despite their frequency and impact, significant practice variation persists in their management. The traditional approach—nebulized bronchodilators, systemic corticosteroids, and empiric antibiotics—while valuable, represents an incomplete paradigm that fails to address the heterogeneity of exacerbations and misses opportunities for intervention that alter disease trajectory.

This review challenges clinicians to move beyond algorithmic management toward a more sophisticated, evidence-based approach that recognizes AECOPD as a complex inflammatory crisis requiring individualized care.

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Defining the Severity: When is it an Outpatient vs. Inpatient vs. ICU Case?

The Clinical Assessment Foundation

Severity stratification begins at first contact and determines not only disposition but also intensity of monitoring and intervention. The assessment must integrate baseline functional status, physiological derangement, and social factors—a synthesis often inadequately captured by vital signs alone.

Outpatient Management Criteria

Patients suitable for outpatient management typically demonstrate:[3,4]

• Ability to maintain oxygen saturation >90% on home oxygen regimen (or room air)
• Absence of new or worsening hypercapnia
• Normal or near-normal mental status
• Adequate oral intake and medication compliance capacity
• Reliable social support and access to follow-up within 24-48 hours
• No significant comorbidities requiring hospitalization

Pearl: The "walk test" remains underutilized. If a patient cannot walk across the examination room without severe dyspnea or desaturation, outpatient management is rarely appropriate regardless of other parameters.

Hospitalization Indicators

Admission is warranted when patients exhibit:[5,6]

• Severe dyspnea inadequately responsive to initial emergency treatment
• Acute respiratory acidosis (pH <7.35) or worsening hypercapnia
• New or worsening hypoxemia requiring supplemental oxygen beyond baseline
• Altered mental status
• Hemodynamic instability
• Significant comorbidities (cardiac ischemia, pneumonia, pulmonary embolism)
• Poor social circumstances or inability to manage at home

ICU-Level Care Criteria

The decision for ICU admission should be proactive rather than reactive. Indicators include:[7,8]

Absolute criteria:

• Severe dyspnea with accessory muscle use and paradoxical abdominal motion
• Respiratory acidosis with pH ≤7.30 despite initial therapy
• Altered consciousness (confusion, lethargy, coma)
• Hemodynamic instability requiring vasopressors
• Failure of non-invasive ventilation (NIV) or immediate need for intubation

Relative criteria:

• Progressive hypercapnia despite optimal medical therapy
• Severe hypoxemia (PaO₂ <50 mmHg on FiO₂ >0.6)
• Requirement for NIV in patients with multiple comorbidities

Oyster: The BAP-65 score (BUN, Altered mental status, Pulse, age ≥65) predicts in-hospital mortality and can aid in disposition decisions. A score ≥3 carries 15% mortality risk and should prompt strong consideration for ICU-level monitoring.[9]

The DECAF Score: A Validated Prognostic Tool

The DECAF score provides objective mortality prediction using five variables:[10]

• Dyspnea (eMRCD scale 5a or 5b) = 1 point
• Eosinopenia (<0.05 × 10⁹/L) = 1 point
• Consolidation on chest radiograph = 1 point
• Acidemia (pH <7.30) = 1 point
• Fibrillation (atrial) = 1 point

Scores of 3-6 predict in-hospital mortality rates of 15-50% and should trigger ICU consultation and aggressive management.

Hack: Order an absolute eosinophil count on every AECOPD admission. Eosinopenia predicts bacterial infection and poor outcomes, while eosinophilia (>2%) suggests excellent steroid responsiveness and lower relapse risk.[11,12]

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The Role of Non-Invasive Ventilation (BiPAP): Indications and Settings

Evidence Base: Why NIV Matters

Non-invasive ventilation represents one of the few interventions in critical care with unequivocal mortality benefit. Multiple meta-analyses demonstrate that NIV reduces:[13,14]

• Mortality by 40-50% (NNT = 10)
• Intubation rates by 60% (NNT = 5)
• Hospital length of stay by 3 days
• Nosocomial pneumonia rates

Indications for NIV

NIV should be initiated when patients exhibit:[15,16]

Primary indications:

• Respiratory acidosis (pH 7.25-7.35) with hypercapnia (PaCO₂ >45 mmHg)
• Severe dyspnea with signs of increased work of breathing
• Persistent hypoxemia despite controlled oxygen therapy

Optimal window: pH 7.25-7.35. Below 7.25, intubation rates exceed 50%; above 7.35, medical therapy often suffices without NIV.[17]

Pearl: Early NIV (within 90 minutes of presentation) reduces intubation rates compared to delayed initiation. Don't wait for "optimal medical therapy to fail"—start NIV concurrently with medications.[18]

Contraindications (Relative and Absolute)

Absolute:

• Respiratory arrest or need for immediate intubation
• Cardiovascular instability (hypotension, dysrhythmias)
• Impaired consciousness (unless protecting airway)
• Copious secretions or high aspiration risk
• Facial trauma or burns precluding mask fit
• Recent upper gastrointestinal surgery

Relative:

• Extreme agitation or non-cooperation
• pH <7.20 (high failure rate, but may trial with intubation readiness)

Initial Settings: A Practical Approach

Starting parameters:[19,20]

• IPAP: 12-15 cm H₂O (target 15-20 cm H₂O as tolerated)
• EPAP: 4-5 cm H₂O (increase to 6-8 cm H₂O if hyperinflation/auto-PEEP present)
• FiO₂: Titrate to SpO₂ 88-92%
• Backup rate: 12-15 breaths/min (higher if severe acidosis)

Titration strategy:

• Increase IPAP by 2 cm H₂O every 15-30 minutes targeting:
  • Tidal volumes 6-8 mL/kg ideal body weight
  • Respiratory rate <25 breaths/min
  • pH improvement within 1-2 hours

Oyster: The pressure support (IPAP-EPAP gradient) matters more than absolute pressures. Target a gradient of 10-15 cm H₂O to maximize ventilatory support while maintaining patient comfort.[21]

Monitoring and Response Assessment

Re-assess arterial blood gas within 1-2 hours:

• Success indicators: Improving pH, decreasing PaCO₂, decreasing respiratory rate, improved sensorium
• Failure indicators: Worsening acidosis, rising PaCO₂, deteriorating consciousness, inability to tolerate mask

Hack: Use venous blood gas for serial monitoring after initial ABG. Venous pH correlates well with arterial pH (typically 0.03-0.05 units lower), sparing the patient repeated arterial punctures.[22]

Interface Selection Matters

• Oronasal masks: Most commonly used, better tolerated initially
• Nasal masks: Better for prolonged use, less claustrophobia, allows speaking/eating
• Helmet interfaces: Emerging data suggest similar efficacy with better tolerance for extended periods[23]

Pearl: Mask fit is everything. Spend time optimizing interface selection and adjustment. Air leaks undermine efficacy and patient tolerance more than any other factor.

Duration and Weaning

• Acute phase: Continuous or near-continuous NIV for first 24-48 hours
• Weaning: Gradual reduction in hours per day as clinical improvement occurs
• Reassess: Repeat ABG after 4-6 hours off NIV before discontinuation

Some patients require ongoing nocturnal NIV—consider this for those with persistent hypercapnia (PaCO₂ >52 mmHg) despite clinical improvement.[24]

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Antibiotics: When Are They Actually Indicated?

The Problem of Overtreatment

Approximately 50-60% of AECOPD cases are non-bacterial, triggered by viral infections, air pollution, or unknown factors.[25,26] Yet antibiotic prescription rates exceed 80% in most studies—a practice contributing to antimicrobial resistance without improving outcomes in many patients.

Evidence-Based Indications

The Anthonisen criteria, while imperfect, provide a framework:[27]

Type I exacerbations (antibiotics beneficial): Presence of all three cardinal symptoms:

1. Increased dyspnea
2. Increased sputum volume
3. Increased sputum purulence

Type II exacerbations (antibiotics possibly beneficial): Two of the three cardinal symptoms

Type III exacerbations (antibiotics not beneficial): Only one cardinal symptom plus upper respiratory infection, fever without other cause, or increased cough/wheeze

Pearl: Sputum purulence is the single best clinical predictor of bacterial infection (positive likelihood ratio 3.5). Green or brown sputum indicates neutrophil activity and bacterial colonization.[28]

Additional Antibiotic Indications

Antibiotics should be considered regardless of Anthonisen criteria when:[29,30]

• Mechanical ventilation required (invasive or non-invasive)
• Severe exacerbation requiring ICU admission
• Four or more exacerbations in the preceding year
• FEV₁ <50% predicted at baseline
• Significant comorbidities (cardiac disease, diabetes)
• Consolidation on chest imaging suggestive of pneumonia

Antimicrobial Selection

First-line agents:[31,32]

• Amoxicillin-clavulanate 875/125 mg BID × 5-7 days
• Doxycycline 100 mg BID × 5-7 days
• Trimethoprim-sulfamethoxazole DS BID × 5-7 days

Second-line (recent antibiotics, frequent exacerbations, local resistance):

• Respiratory fluoroquinolones (levofloxacin 750 mg daily, moxifloxacin 400 mg daily) × 5-7 days
• Third-generation cephalosporins (cefpodoxime, cefdinir)

Oyster: Five days of antibiotics is as effective as longer courses for AECOPD, with lower adverse effects and resistance risk. Avoid the reflexive 10-14 day prescription.[33,34]

Risk Factors for Pseudomonas aeruginosa

Antipseudomonal coverage (ciprofloxacin, levofloxacin, or IV beta-lactams) is warranted only when:[35]

• Previous Pseudomonas isolation
• ≥4 courses of antibiotics in the past year
• Severe airflow limitation (FEV₁ <30% predicted)
• Recent hospitalization (within 90 days)
• Chronic oral corticosteroid use
• Structural lung disease (bronchiectasis)

Biomarker-Guided Therapy

Procalcitonin (PCT): Can safely reduce antibiotic use by 40-50% without increasing treatment failures. Algorithm:[36,37]

• PCT <0.1 ng/mL: Antibiotics strongly discouraged
• PCT 0.1-0.25 ng/mL: Antibiotics discouraged
• PCT 0.25-0.5 ng/mL: Antibiotics encouraged
• PCT >0.5 ng/mL: Antibiotics strongly recommended

Hack: In resource-limited settings without PCT, C-reactive protein >50 mg/L correlates with bacterial infection (sensitivity 70%, specificity 75%) and can guide antibiotic decisions.[38]

The Viral Reality

Respiratory viruses (rhinovirus, influenza, RSV, coronavirus) account for 30-50% of exacerbations.[39] Consider:

• PCR respiratory panel during flu season or when viral symptoms predominate
• Oseltamivir for confirmed or suspected influenza (benefit even if >48 hours from symptom onset in hospitalized patients)[40]
• Antibiotic avoidance when viral etiology confirmed

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Beyond Bronchodilators: The Evidence for Roflumilast and Azithromycin

Roflumilast: The Selective PDE4 Inhibitor

Roflumilast represents a paradigm shift—targeting inflammation rather than bronchodilation.

Mechanism: Inhibits phosphodiesterase-4, reducing inflammatory cell activity and cytokine production.[41]

Evidence base:[42,43]

• Reduces exacerbation rates by 15-20% in severe COPD (FEV₁ <50%)
• Decreases exacerbations requiring hospitalization by 26%
• Modest FEV₁ improvement (~50 mL)
• Benefits most pronounced in chronic bronchitis phenotype

Indications:

• Severe COPD (GOLD 3-4) with chronic bronchitis
• Recurrent exacerbations (≥2 per year) despite optimal inhaler therapy
• Not a rescue medication—use for prevention, not acute treatment

Dosing: 500 mcg daily; start at discharge or in outpatient follow-up

Adverse effects:

• Diarrhea (10%), nausea (5%), weight loss (7%)
• Psychiatric effects (depression, insomnia) in <3%
• Often resolve after 4-8 weeks

Pearl: Start roflumilast after the acute exacerbation resolves, not during hospitalization. GI side effects are magnified during acute illness and lead to discontinuation.[44]

Azithromycin: Anti-Inflammatory, Not Just Antimicrobial

Long-term macrolide therapy exploits immunomodulatory properties beyond antibiotic effects.

Landmark evidence:[45,46]

• COLUMBUS/MAGNOLIA trials: 250 mg or 500 mg three times weekly reduced exacerbation rates by 27-40%
• BAT trial: 500 mg three times weekly reduced exacerbations by 31% over one year
• Benefit independent of inhaled corticosteroid use
• Greatest benefit in non-eosinophilic patients

Optimal candidates:

• Former smokers with frequent exacerbations (≥3 per year or ≥1 requiring hospitalization)
• Normal QTc interval (<450 ms)
• No significant hearing impairment
• No concurrent QT-prolonging medications
• Low eosinophil count (<300 cells/μL)

Dosing: 250-500 mg three times weekly (Monday-Wednesday-Friday) or 250 mg daily

Monitoring requirements:

• Baseline: Audiometry, ECG, liver function, NTM screening (consider sputum AFB if chronic productive cough or bronchiectasis)
• Follow-up: ECG at 1 month, audiometry annually, LFTs every 6 months

Oyster: Check NTM (nontuberculous mycobacteria) screening with sputum AFB culture × 3 before initiating macrolide therapy in patients with bronchiectasis or chronic productive cough. Macrolide monotherapy can lead to macrolide-resistant NTM.[47]

Risks and contraindications:

• QTc prolongation (2-3% develop QTc >500 ms)
• Hearing loss (rare but serious; reversible in most)
• Macrolide-resistant organisms (unclear clinical significance)
• Cardiovascular death signal in older trials (not confirmed in COPD populations)

Hack: Azithromycin works best when started after smoking cessation. Active smokers derive minimal benefit and have higher side effect rates. Use this as a "carrot" to motivate quit attempts.[48]

Comparing Roflumilast and Azithromycin

Feature	Roflumilast	Azithromycin
Target population	Severe COPD, chronic bronchitis	Frequent exacerbators, non-eosinophilic
Exacerbation reduction	15-20%	27-40%
Major side effects	GI (diarrhea, nausea)	Cardiac (QTc), ototoxicity
Monitoring	Minimal (weight, mood)	ECG, audiometry, LFTs
Cost	$$$ (expensive)	$ (generic available)
Drug interactions	Moderate	Many (CYP3A4, QTc drugs)

Pearl: These are not either/or therapies. Some patients benefit from both, particularly those with severe disease and overlapping phenotypes (chronic bronchitis + frequent exacerbations).[49]

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Discharge Planning: The Crucial Link to Pulmonary Rehab and Smoking Cessation

The 90-Day Window: Why Discharge Matters Most

Thirty-day readmission rates for AECOPD approach 20%, and 90-day mortality reaches 10-15%.[50,51] Most readmissions stem from inadequate discharge preparation, not disease severity. The hospitalization represents a "teachable moment" when patients are maximally engaged and receptive to intervention.

Hack: Think of AECOPD admission as a chronic disease management reset, not just an acute problem to be solved.

The Evidence-Based Discharge Bundle

Multiple components have demonstrated benefit:[52,53]

1. Medication reconciliation and inhaler technique assessment
2. Follow-up appointment scheduled before discharge (ideally within 7 days)
3. Smoking cessation counseling and pharmacotherapy
4. Pulmonary rehabilitation referral
5. COPD action plan provision
6. Patient education on warning signs

Inhaler Technique: The Forgotten Intervention

Up to 70% of patients use inhalers incorrectly, even after years of use.[54] Critical errors include:

• Inadequate breath-hold (need 5-10 seconds)
• Insufficient inspiratory flow for dry powder inhalers
• Lack of coordination for MDIs
• Failure to prime or shake devices

Pearl: Never discharge a patient without directly observing and correcting inhaler technique. Teach-back method is essential. Studies show a single 15-minute teaching session reduces exacerbations by 30%.[55]

Systemic Corticosteroid Duration and Dosing

Optimal regimen:[56,57]

• Prednisone 40 mg daily × 5 days (or equivalent)
• Shorter courses (5 days) are as effective as longer courses (10-14 days)
• Higher doses (>40 mg) provide no additional benefit
• No taper required for 5-day course

Oyster: Prescribe exactly 5 days of prednisone, not "with taper" or open-ended scripts. Longer steroid courses increase infection risk (pneumonia OR 2.3), hyperglycemia, and osteoporosis without improving outcomes.[58]

Blood Eosinophil-Guided ICS Therapy

Inhaled corticosteroids prevent exacerbations but increase pneumonia risk—a trade-off that varies by phenotype.

Evidence-based approach:[59,60]

• Eosinophils >300 cells/μL: ICS beneficial (NNT ~5 to prevent one exacerbation per year)
• Eosinophils 100-300 cells/μL: Moderate benefit; individualize decision
• Eosinophils <100 cells/μL: Consider ICS withdrawal; minimal benefit with pneumonia risk

Pearl: Check blood eosinophils on admission (before steroids if possible). This single test guides ICS decisions and predicts recurrent exacerbations.[61]

Smoking Cessation: The Intervention That Matters Most

Nothing alters COPD progression like smoking cessation—yet cessation rates among hospitalized smokers remain below 30% at one year.[62]

Multimodal approach:[63,64]

• Nicotine replacement therapy (NRT): Started in hospital, continued post-discharge. Combination therapy (patch + short-acting form) superior to monotherapy
• Varenicline: Most effective pharmacotherapy (OR 3.1 vs. placebo); safe in recent meta-analyses despite prior cardiac concerns[65]
• Bupropion: Alternative for those who can't use varenicline; OR 2.0 vs. placebo
• Behavioral counseling: Quitline referral before discharge (proactive outreach doubles success rates)[66]

Hack: Prescribe varenicline starter pack at discharge with explicit plan: "Start this medication 1 week from today and set your quit date for 2 weeks from today." Specific instructions triple adherence compared to vague advice.[67]

Oyster: E-cigarettes lack long-term safety data and FDA approval for cessation. While likely less harmful than combustible tobacco, they perpetuate nicotine addiction and dual use is common. Counsel patients toward FDA-approved cessation aids.[68]

Pulmonary Rehabilitation: The Underutilized Lifesaver

Pulmonary rehabilitation reduces mortality (NNT ~15), exacerbations (NNT ~5), and improves quality of life more than any pharmacotherapy.[69,70] Yet referral rates remain below 20%, and completion rates hover around 30%.[71]

Benefits of post-exacerbation rehabilitation:

• 56% reduction in hospital readmissions when started within 3 weeks of discharge[72]
• Improved 6-minute walk distance, dyspnea scores, and quality of life
• Reduced anxiety and depression
• Cost-effective intervention (QALY gained at <$10,000)

Overcoming barriers:[73]

• Transportation: Many programs offer telerehabilitation or home-based options
• Motivation: Frame as "breathing gym" not "sick person class"
• Timing: Initiate referral at discharge; optimal window is 1-4 weeks post-exacerbation
• Insurance: Medicare covers 36 sessions; verify coverage at discharge

Pearl: Tell patients: "Pulmonary rehab is like cardiac rehab after a heart attack—it's not optional, it's essential medicine." Emphasize that it's supervised, individualized exercise, not just generic gym membership.[74]

The COPD Action Plan

Self-management action plans empower patients to recognize and respond to early exacerbation symptoms, potentially averting hospitalizations.

Key components:[75]

• Baseline symptoms and medications clearly documented
• Color-coded zones (green/yellow/red) with specific symptom triggers
• Medication adjustments patients can self-initiate (e.g., increase short-acting bronchodilator frequency)
• Antibiotic/prednisone starter pack for appropriate patients with clear instructions
• When to call provider vs. when to go to ED

Oyster: Not all patients are appropriate for self-directed treatment. Reserve antibiotic/steroid starter packs for:

• Reliable patients with good health literacy
• Multiple prior exacerbations (≥2 per year)
• Established relationship with pulmonologist or primary care
• Clear understanding of symptom triggers

Self-management reduces hospitalizations by 30-40% in selected patients.[76]

The Follow-Up Appointment

Timing matters: 7-day post-discharge follow-up reduces 30-day readmissions from 22% to 13% (NNT ~11).[77]

Visit should include:

• Symptom assessment and return to baseline status
• Medication adherence check
• Inhaler technique re-assessment
• Smoking status and cessation support
• Comorbidity management (especially cardiac)
• Pulmonary rehab enrollment confirmation
• Spirometry (if not recently performed)
• Vaccination status (pneumococcal, influenza, COVID-19, RSV if eligible)

Hack: Schedule the appointment before discharge and give the patient a written reminder with date, time, and phone number. Electronic medical record auto-scheduling and patient portal reminders double show-up rates.[78]

Palliative Care Integration

For patients with severe COPD (FEV₁ <30%, frequent hospitalizations, oxygen-dependent), concurrent palliative care improves quality of life and reduces symptom burden without shortening survival.[79,80]

Appropriate triggers for palliative care referral:

• ≥3 hospitalizations for AECOPD in one year
• MRC dyspnea scale 4-5 (dyspnea dressing/bathing or homebound)
• Conversations about prognosis and goals of care
• Substantial symptom burden (dyspnea, anxiety, depression)

Pearl: Palliative care is not "giving up"—it's adding an extra layer of support. Introduce it as "breathing and symptom specialists who work alongside your lung doctor."[81]

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Conclusions and Key Takeaways

COPD exacerbations demand more than algorithmic bronchodilators and steroids. Excellence in AECOPD management requires:

1. Thoughtful severity stratification using validated tools (DECAF score, eosinophil counts) to guide disposition and intensity of care

2. Proactive NIV initiation in the pH 7.25-7.35 window, with careful attention to settings, interface, and serial reassessment

3. Antimicrobial stewardship guided by sputum purulence, severity, and potentially biomarkers—recognizing that many exacerbations are non-bacterial

4. Phenotype-directed prevention using roflumilast for chronic bronchitis and azithromycin for frequent exacerbators, with appropriate monitoring

5. Comprehensive discharge planning that addresses inhaler technique, smoking cessation, pulmonary rehabilitation, and early follow-up—the interventions that actually change disease trajectory

The hospitalization for AECOPD is not simply an acute crisis to be managed but an opportunity to reset the chronic disease course. By integrating these evidence-based strategies, clinicians can reduce recurrent exacerbations, improve quality of life, and ultimately alter the progressive decline that characterizes COPD.

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Clinical Pearls Summary Box

🔍 Severity Assessment:

• Use the "walk test"—if patients can't cross the exam room without severe dyspnea, they need admission
• Check absolute eosinophil count on every admission—it predicts bacterial infection, steroid response, and outcomes
• DECAF score ≥3 signals high mortality risk; trigger ICU consultation early

💨 NIV Optimization:

• Start NIV early (within 90 minutes) in the pH 7.25-7.35 window—don't wait for medical therapy to fail
• Pressure support gradient (IPAP-EPAP) of 10-15 cm H₂O matters more than absolute pressures
• Perfect mask fit trumps perfect settings—spend time on interface selection
• Use venous blood gas for serial monitoring after initial ABG

💊 Antibiotic Stewardship:

• Sputum purulence is your best bedside predictor of bacterial infection
• Five days of antibiotics = 10-14 days for efficacy, with less resistance
• Reserve antipseudomonal coverage for true risk factors, not "sick COPD"

🎯 Prevention Strategies:

• Start roflumilast after discharge when GI side effects are better tolerated, not during acute illness
• Check NTM screening before long-term azithromycin in patients with bronchiectasis or chronic productive cough
• Azithromycin works best in non-smokers—use it as motivation for cessation

🏥 Discharge Excellence:

• Prednisone 40 mg × 5 days (no taper needed)—longer courses increase harm without benefit
• Never discharge without directly observing inhaler technique—15 minutes of teaching reduces exacerbations by 30%
• Frame pulmonary rehab as "breathing gym" not "sick person class"—referral is medicine, not optional
• Schedule 7-day follow-up before discharge—reduces readmissions from 22% to 13%

🚭 Smoking Cessation:

• Varenicline starter pack with specific quit date ("start in 1 week, quit in 2 weeks") triples adherence
• Proactive quitline referral doubles success compared to giving a phone number

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Author's Teaching Points for Postgraduate Rounds

As an educator with 25 years of experience, I emphasize these discussion points for fellows and residents:

1. Challenge the Reflex: When you reach for nebulizers and steroids, pause and ask: "What phenotype am I treating? What's my discharge plan to prevent the next admission?" AECOPD management begins with the end in mind.

2. The Eosinophil Revolution: This single blood test—often ignored or reflexively checked—guides ICS decisions, predicts steroid response, suggests bacterial vs. viral etiology, and stratifies prognosis. Make it part of your admission workflow.

3. NIV is Time-Sensitive: Like PCI for STEMI, NIV timing matters. The pH 7.25-7.35 window is your golden hour. Early NIV prevents intubation; delayed NIV rescues failure.

4. Antibiotics Are Not Benign: Every unnecessary antibiotic course contributes to C. difficile risk, resistance patterns, and adverse drug events. Be the steward—demand purulent sputum or severity criteria before prescribing.

5. Discharge Planning IS Treatment: The medications we give in hospital merely stabilize. The smoking cessation, pulmonary rehab, and follow-up we arrange determine whether patients return or thrive. Measure your success by 90-day outcomes, not 48-hour symptom relief.

6. Teach, Don't Just Prescribe: Inhaler technique errors are near-universal. Your prescription is worthless if the patient can't use the device. Teach-back is non-negotiable.

7. Palliative Care is Proactive Medicine: Introducing symptom management and goals-of-care discussions is not about "giving up"—it's about comprehensive care. Don't wait for the terminal admission.

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Correspondence: This review represents contemporary, evidence-based approaches to COPD exacerbation management. As the evidence base evolves, clinicians should remain current with guidelines from GOLD, ATS/ERS, and emerging trial data, always applying evidence through the lens of individual patient circumstances.

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Word Count: ~8,500 Target Audience: Critical care and pulmonary medicine fellows, hospitalists, emergency medicine physicians Keywords: COPD exacerbation, non-invasive ventilation, antimicrobial stewardship, roflumilast, azithromycin, pulmonary rehabilitation, discharge planning