Managing Chronic and Acute COPD Exacerbations

Ashley Huntsberry, PharmD, BCACP; Kimberly Won, PharmD, BCCCP


US Pharmacist. 2018;43(7):HS13-HS17. 

In This Article

Abstract and Introduction


Healthcare professionals across the world utilize the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline to guide the diagnosis, management, and prevention of chronic obstructive pulmonary disease (COPD). The guideline incorporates evidence-based recommendations regarding the assessment of disease severity, choice of pharmacologic treatment, and strategies for the management and prevention of acute exacerbations. The GOLD guideline recently underwent a major revision in 2017, in addition to a minor revision in 2018, to account for new evidence surrounding the assessment of disease severity, as well as therapeutic recommendations for the management of COPD. The updated GOLD report includes a simplified version of the ABCD assessment tool, which separates symptoms and exacerbation risk from the severity of airflow limitation. Additionally, there were also modifications to the pharmacotherapy treatment algorithm and new recommendations for the prevention and management of acute COPD exacerbations.


Since 2001, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) has released guidelines to provide clinicians with the tools they need to properly and consistently diagnose, manage, and prevent COPD. The GOLD report defines COPD as a preventable disease characterized by progressive airflow limitation and persistent respiratory symptoms.[1–3] Tobacco smoke is one of the greatest risk factors for the development of COPD.

Aside from tobacco smoke, exposure to noxious particles from the environment and various host factors, including genetics, age, and airway hyper-responsiveness, also influence disease development.[3] The World Health Organization projects that by the year 2030, COPD will be the third-leading cause of death worldwide owing to an increase in risk-factor exposure and the aging of the world's population.[3,4]

The management of COPD depends on the assessment of disease severity. The degree of chronic airflow limitation is measured by spirometry and progresses at varying rates over time, differing from person to person.[3] As the lungs are exposed to noxious particles or gases, they become inflamed. Over time, chronic inflammation causes structural changes to the airway, resulting in progressive airflow limitation seen upon spirometry.[3] The structural narrowing of the peripheral airways, in addition to the chronic inflammation, is directly related to the reduction in the volume of air exhaled at the end of the first second of forced expiration (FEV1) typically seen in patients with COPD.[3,5]

A diagnosis of COPD, therefore, should be considered in patients with a prior history of risk-factor exposure, in addition to symptom development such as dyspnea, chronic cough, or sputum production.[3] To establish an official diagnosis of COPD in a patient with risk factors and symptoms, a postbronchodilator FEV1 to forced vital capacity (FVC) ratio (FEV1/FVC) < 0.70 is required to confirm the presence of airflow limitation utilizing spirometry.[2,3] The 2018 GOLD report emphasizes the need to perform an additional spirometry test at a later date if the FEV1/FVC ratio value is between 0.6 and 0.8 to account for variation in measurements.[3] The updated guideline also no longer recommends measuring FEV1 before and after a bronchodilator in an attempt to assess the degree of airflow limitation reversibility, as it provides no additional benefit in the diagnosis or management of COPD.[2,3]