Snapshot A 68-year-old man with a history of hypertension, heart failure, and emphysema presents to the emergency department with worsening shortness of breath and purulent sputum production. His symptoms began approximately 4 days ago, where he has had difficulty cleaning around the house and walking 1 block. Prior to this event, he was able to walk 7-10 blocks without much difficulty and did not experience dyspnea at rest. He has a 45-pack-year smoking history. He has not received the influenza vaccine. He has been hospitalized 5 times within the past year for similar symptoms. He is febrile and his oxygen saturation is 85% on room air. On physical exam, the patient appears uncomfortable and is having trouble completing his sentences. Chest radiography demonstrates hyperinflated lungs. A sputum culture is obtained and an arterial blood gas is significant for hypercarbia, hypoxemia, and acidemia. He is started on supplemental oxygen, inhaled ipratropium, albuterol, intravenous methylprednisolone, and levofloxacin. Introduction Definition an acute worsening of a patient's respiratory symptoms leading to a change in treatment cardinal symptoms of an acute change include an increased frequency and severity of a cough sputum volume or character change dyspnea Prevention influenza vaccine 23-valent pneumococcal polysaccharide vaccine (PPSV23) 13-valent pneumococcal conjugate vaccine (PCV13) for all patients ≥ 65 years of age Epidemiology Risk factors advanced age duration of COPD history of antibiotic therapy worsened FEV1 a productive cough peripheral eosinophilia Etiology Respiratory infections most commonly H. influenzae, M. catarrhalis, and S. pneumoniae patients are at increased risk for P. aeruginosa infection when they have multiple hospitalizations in the past advanced COPD previous isolation of Pseudomonas from sputum concomitant bronchiectasis frequent antibiotic treatment systemic glucocorticoid use Congestive heart failure Pulmonary embolism Presentation Symptoms worsening dyspnea and cough increased sputum production or change in sputum character Physical exam wheezing tachypnea patients may have difficulty speaking due to respiratory effort accessory respiratory muscle use asynchrony between chest and abdominal motion with respiration confusion (secondary to hypercarbia and hypoxemia) Imaging Chest radiography indication initial imaging modality of choice used to determine etiology for the COPD exacerbation, such as pneumonia congestive heart failure Studies Arterial blood gas findings hypercarbia, hypoxemia, and acidosis Pulse oximetry Treatment Conservative O2 supplementation indication used to improve oxygen saturation to 88-92% or a PaO2 of approximately 60 to 70 mmHg comments the only treatment to improve mortality in patients with COPD Medical ipratropium and albuterol indication typically used in combination for patients with a COPD exacerbation Magnesium relaxes smooth muscle systemic corticosteroids indication typically used in patients with a COPD exacerbation medications prednisolone (oral) methylprednisolone (intravenous) use in patients who cannot tolerate oral medications comments decreases treatment failure and hospital stay antibiotics high P. aeruginosa risk levofloxacin piperacillin-tazobactam cefipime ceftazidime low P. aeruginosa risk moxifloxacin ceftriaxone cefotaxime PROGNOSIS Associated with an increased mortality