Abstract：Objective To evaluation the efficacy of nebulized budesonide suspension in the treatment of acute exacerbation of chronic obstructive pulmonary disease （AECOPD） with different levels of blood eosinophils.  Methods A total of 100 eligible AECOPD patients in Shengzhou Hospital of Traditional Chinese Medicine from May 2020 to May 2021 were randomly selected. Among them, 60 cases of patients with blood eosinophils＞300 cell/μl were enrolled in the group A, and 40 patients with blood eosinophils＜100 cell/μl were enrolled in the group B. Each group was then randomly divided into two subgroups：A1（n＝30）and A2（n＝30）, B1（n＝20）and B2（n＝20）. Groups A2 and B2 received standard treatment, while Groups A1 and B1 received nebulized budesonide suspension in addition to standard treatment. Clinical efficacy, time to symptoms improvement, the time of hospitalization, C reactive protein （CRP）, calcitoninogen （PCT）, eosinophil count, and disease severity （mMRC and CAT score）were compared among the four groups.  Results The overall treatment efficacy in Group A1 was 96.67%, significantly higher than in Groups A2 （73.33%）, B1 （75.00%） and B2 （65.00%）（χ2＝8.780, P＝0.032）. After treatment, Group A1 showed significantly shorter times to relief of cough, sputum production, and dyspnea, as well as a shorter hospital stay, compared to the other groups. CRP, PCT, and eosinophil counts were significantly lower, and mMRC and CAT scores were significantly reduced in Group A1 compared to Groups A2, B1, and B2, with all differences being statistically significant （F＝14.815, 11.613, 11.300, 25.008, 12.222, 19.692, 389.189, 5.469, 3.491; all P＜0.05）. Conclusion Nebulized budesonide suspension is significantly more effective in treating AECOPD patients with high blood eosinophil levels than in those with low eosinophil levels. It can markedly improve symptoms and shorten hospitalization time.