We developed a concept of VR in patients with acute exacerbation of advanced COPD and tested the hypothesis that it is predictable and clinically useful in the ER. Our concept of VR was based on the idea that a threshold VF and a MSV capacity are measurable; ie, VR = MSV - VF. We measured resting minute ventilation, the 15-s MVV, FEV1 and ABG values in 13 patients with exacerbation of COPD in the ER and 11 stable subjects with similar degrees of COPD. We tested if measures of VR could distinguish between ER patients progressing to respiratory failure, ER patients who avoided progression to respiratory failure and stable patients. There were significant differences in measures of the mean VR between various groups of patients. We conclude that in this COPD population, VR can be accurately predicted in the ER and that it may be a clinically valid predictor of patient outcomes.