An Evidence-Informed Clinical Pathway for COPD Exacerbations in Emergency Departments: Diagnostic Assessment, Severity Stratification, and Individualized Management

Background/Objectives: Exacerbations of chronic obstructive pulmonary disease (COPD) are a common reason for emergency department (ED) attendance and hospital admission. Acute respiratory worsening is non-specific, and previous spirometric confirmation may be unavailable at presentation. We aimed to translate current recommendations into an ED-specific clinical pathway that standardizes safety-critical steps without replacing individualized clinical judgment. Methods: We performed a targeted synthesis of international and Spanish guidance and key studies relevant to ED diagnosis, severity assessment, pharmacological treatment, respiratory support, antimicrobial stewardship, and disposition. The evidence base was updated in June 2026, and the pathway was reviewed by a multidisciplinary clinical group. Results: The revised pathway comprises four stages: (1) verify previous COPD confirmation, identify an acute exacerbation-like syndrome, and assess alternative or concomitant diagnoses; (2) grade acute severity using point-of-care variables and separately assess patient vulnerability; (3) provide severity-adjusted treatment with early reassessment; and (4) determine disposition and follow-up. It incorporates controlled oxygen, individualized bronchodilator delivery, explicit criteria for systemic corticosteroids and antibiotics, assessment of risk for Pseudomonas aeruginosa, non-invasive ventilation (NIV), and a defined adjunctive role for high-flow nasal cannula (HFNC). Patients without previous post-bronchodilator spirometry are classified as having suspected COPD and require confirmation after recovery. Conclusions: This evidence-informed pathway is a preliminary clinical framework, not a diagnostic rule or validated decision instrument. It is intended to support, rather than replace, professional judgment. Feasibility, acceptability, diagnostic safety, and clinical impact require prospective evaluation, beginning with a pilot implementation study.