-Encompasses chronic bronchitis (“blue bloaters”) and emphysema (“pink puffers”)

Pathophysiology: Inflammation leading to mucus hypersecretion and destruction of alveolar walls. Airway walls become weak and close (or “obstruct”) as patient tries to exhale, trapping air and CO2 in the lungs

Risk factors:

  1. Smoking
  2. Alpha-1-antitrypsin deficiency (genetic)
  3. Intravenous Drug Use
  4. HIV


  • Outpatient
    • Pulmonary Function Tests
      • Obstruction diagnosed by: FEV1/FVC < 0.7
      • No bronchodilator response (<12% increase or <200 mL increase in TV)
      • No methacholine response
      • Emphysema: Decrease in DLCO
      • Chronic Bronchitis: Normal DLCO
  • Inpatient “Exacerbation” (if patient has known COPD)
    • New cough
    • Change in sputum production (increased amount or change in color)
    • Increase in dyspnea
    • ABG may show increased PaCO2 (due to retention) and a low pH

Outpatient Management

  • Non-Pharmacologic
    • Smoking cessation
    • Exercise regimen
    • Supplemental Oxygen (target an SpO2 ~88-92)
    • Immunization (Influenza and Pneumococcal)
    • BiPAP (if CO2 retention)
    • Procedures
      • Lung reduction surgery (especially if COPD worse in upper lobes)
      • Placement of one-way endobronchial valves
      • Lung transplant
  • Pharmacologic
    1. SABA or SAMA (Short-Acting Beta-Agonist or Short-Acting Muscarinic Antagonist)
      • Can combine if necessary
      • Can use nebulizers if patients have difficulty with inhalation
      • Ex. albuterol (SABA), ipraptropium (SAMA)
    2. LABA or LAMA (Long-Acting Beta-Agonist or Long-Acting Muscarinic Antagonist)
      • Whichever is started first, other can be added as next step
      • Ex. formoterol, salmeterol (LABAs), tiotropium, aclidinium (LAMAs)
    3. ICS (Inhaled corticosteroids)
      • Ex. Fluticasone, mometasone, budesonide
      • Especially beneficial in patients with peripheral eosinophilia
    4. Antibiotics
      • Macrolides have been shown to decrease frequency of exacerbations (usually Monday, Wednesday, Friday dosing)
    5. Roflumilast
      • Phosphodiesterase-4 Inihibitor
      • Can help prevent re-hospitalization
      • Notable side effect: Diarrhea
    6. Biologic Agents (if asthma-COPD overlap syndrome)
      • Ex. Omalizumab (anti-IgE) vs mepolizumab (anti-IL-5)

Inpatient “Exacerbation” Management

  • Investigate underlying cause of exacerbation
    • Chest X-Ray: to rule out alternative diagnosis
    • Respiratory viral panel
    • CBC: Assess for polycythemia, anemia, or leukocytosis
    • EKG: to look for underlying ischemia
    • Consider CTA if concern for PE
  • Acute Respiratory Failure
    • Supplemental oxygen
      • Nasal cannula vs heated high-flow
      • BiPAP
      • Intubation if necessary
  • Obstruction
    • Stop home inhalers
    • Start combined albuterol/ipratropium nebulizer scheduled (NOT PRN) q4hours-q6hours
  • Inflammation
    • Steroids
      • Typically start with IV methylprednisolone on day 1 (40-120 mg x1 dose)
      • Change to PO prednisone 40 mg qday on the second day (course of 5-10 days)
    • Antibiotics
      • Azithromycin, doxycyline, levofloxacin for anti-inflammatory effects as well as to cover atypical pathogens for a course of 5-7 days

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