From the Guidelines
Management of acute COPD exacerbations requires prompt intervention with bronchodilators, corticosteroids, and antibiotics when appropriate, with a focus on minimizing morbidity, mortality, and improving quality of life. The most recent and highest quality study 1 recommends the use of systemic glucocorticoids, such as prednisone 40mg daily for 5 days, to improve lung function, oxygenation, and shorten recovery time and hospitalization duration.
Key Components of Management
- Short-acting bronchodilators like albuterol (2.5-5mg nebulized every 4-6 hours) or ipratropium (0.5mg nebulized every 6-8 hours) should be administered immediately to relieve bronchospasm 1.
- Systemic corticosteroids, such as prednisone 40mg daily for 5 days, help reduce airway inflammation and improve outcomes 1.
- For patients with signs of bacterial infection (increased sputum purulence, volume, or dyspnea), antibiotics are indicated; options include amoxicillin-clavulanate 875/125mg twice daily, doxycycline 100mg twice daily, or azithromycin 500mg on day 1 followed by 250mg daily for 4 days 1.
- Supplemental oxygen should be provided to maintain oxygen saturation between 88-92%, as higher levels may suppress respiratory drive in some COPD patients 1.
- Non-invasive positive pressure ventilation (NIPPV) should be considered for patients with respiratory acidosis (pH <7.35) or severe dyspnea 1.
Monitoring and Prevention
- Patients should be monitored for clinical improvement, with attention to respiratory rate, work of breathing, and oxygen saturation 1.
- Addressing the underlying trigger of the exacerbation, such as respiratory infections or environmental exposures, is essential for comprehensive management 1.
- Following the acute phase, patients should receive education on proper inhaler technique, smoking cessation counseling, and a review of maintenance therapy to prevent future exacerbations 1.
From the Research
Acute COPD Exacerbation Management
- Acute COPD exacerbation is characterized by an increase in symptoms such as dyspnea, cough, and sputum production that worsens over a period of 2 weeks 2
- Targeted O2 therapy improves outcomes and should be titrated to an SpO2 of 88-92% 2
- Noninvasive ventilation (NIV) is standard therapy for patients who present with COPD exacerbation and is supported by clinical practice guidelines 2, 3, 4
- Inhaled short-acting bronchodilators can be provided by nebulizer, pressurized metered-dose inhaler, or dry powder inhaler 2
- Management of auto-PEEP is the priority in mechanically ventilated patients with COPD, achieved by reducing airway resistance and decreasing minute ventilation 2
Pharmacological Treatment
- Long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy is recommended over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance 5
- Triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA may be considered over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year 5
- ICS withdrawal may be considered for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year 5
Non-Pharmacological Treatment
- Non-invasive mechanical ventilation (NIMV) is supported by strong evidence of its efficacy in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis 3
- High flow nasal cannulae (HFNC) oxygen therapy may be considered, but further prospective studies are needed 3
- Pulmonary rehabilitation is recommended due to its feasibility and safety, and may be associated with standard treatment of patients 3, 4