What is the management of acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

For the management of acute exacerbation of COPD, prompt treatment with bronchodilators, systemic corticosteroids, and antibiotics is essential to reduce symptoms, improve lung function, and prevent complications 1.

Key Management Steps

• Bronchodilators: Administer short-acting beta-agonists (SABAs) such as albuterol 2.5-5 mg via nebulizer every 4-6 hours as needed, and/or short-acting anticholinergics (SAACs) such as ipratropium 0.5 mg via nebulizer every 4-6 hours as needed 1.
• Systemic Corticosteroids: Prescribe prednisone 40 mg orally once daily for 5-7 days to reduce airway inflammation, as this has been shown to improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1.
• Antibiotics: Use antibiotics such as azithromycin 250-500 mg orally once daily for 5-7 days or doxycycline 100 mg orally twice daily for 5-7 days if there is evidence of bacterial infection, such as increased sputum purulence or a change in sputum color, as this can shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration 1.
• Non-invasive Ventilation (NIV): Consider NIV for patients with severe exacerbations, such as those with respiratory failure or a pH < 7.35, to reduce the need for intubation and improve outcomes, as it improves gas exchange, reduces work of breathing, and decreases hospitalization duration 1.
• Hospitalization: Admit patients to the hospital if they have severe symptoms, such as severe dyspnea, respiratory failure, or a change in mental status, or if they require close monitoring or intensive therapy, highlighting the importance of coordination of care between subspecialists and primary care physicians 1.

It is crucial to individualize treatment based on the patient's medical history, severity of symptoms, and response to therapy, and to provide close monitoring and follow-up to ensure optimal management and prevent future exacerbations 1.

From the FDA Drug Label

Adult PatientsAcute Bacterial Exacerbations of Chronic Obstructive Pulmonary Disease In a randomized, double-blind controlled clinical trial of acute exacerbation of chronic bronchitis (AECB), azithromycin (500 mg once daily for 3 days) was compared with clarithromycin (500 mg twice daily for 10 days). The primary endpoint of this trial was the clinical cure rate at Day 21 to 24 For the 304 patients analyzed in the modified intent to treat analysis at the Day 21 to 24 visit, the clinical cure rate for 3 days of azithromycin was 85% (125/147) compared to 82% (129/157) for 10 days of clarithromycin

The management of acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) may include the use of antibiotics such as azithromycin.

• Key points:
  • Azithromycin may be used for the treatment of acute bacterial exacerbations of COPD.
  • The clinical cure rate for azithromycin was 85% in one study.
  • The use of ipratropium bromide inhalation solution as a single agent for the relief of bronchospasm in acute COPD exacerbation has not been adequately studied 2. No conclusion can be drawn regarding the use of other treatments or management strategies for acute exacerbation of COPD from the provided drug labels. 3

From the Research

Management of Acute Exacerbation of COPD

The management of acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) involves a combination of pharmacological and non-pharmacological treatments.

• Initial clinical evaluation is crucial to define those patients requiring hospital admission and those who could be managed as outpatients 4.
• Medical treatment should follow recent recommendations, including:
  • Rest
  • Titrated oxygen therapy
  • Inhaled or nebulized short-acting bronchodilators (Beta2-agonists and anticholinergic agents)
  • DVT prevention with LMWH
  • Steroids in most severely ill patients, unless there are contraindications
  • Antibiotics in the case of a clear bacterial infectious aetiology 4, 5
• Non-invasive ventilation (NIV) should be the first line ventilatory support for patients with severe exacerbations, unless contraindicated 4, 6, 7.
• Mechanical ventilation through an endotracheal tube should be considered when patients have contraindications to the use of NIV or fail to improve on NIV 4.
• The duration of mechanical ventilation should be shortened as much as possible by an early weaning process, including preventive post-extubation NIV in hypercapnic patients 4.
• Strategies to prevent COPD exacerbations include:
  • Smoking cessation
  • Long-acting inhaled beta-adrenoceptor agonists
  • Inhaled long-acting anticholinergics
  • Inhaled corticosteroids
  • Vaccination
  • Mucolytic agents
  • Pulmonary rehabilitation
  • Case management programmes 5, 8

Non-Pharmacological Treatments

Non-pharmacological treatments for acute exacerbations of COPD include:

• Oxygen therapy, which can be safely administered in acute exacerbations associated with hypoxaemia, with titration of oxygen delivery to a goal oxygen saturation of 90% 5, 7.
• High flow nasal cannulae (HFNC) oxygen therapy, which needs further prospective studies 6.
• Pulmonary rehabilitation, which is recommended due to its feasibility and safety 6, 8.
• Non-invasive ventilation (NIV), which reduces the morbidity and mortality associated with acute exacerbations complicated by hypercapnic respiratory failure 4, 6, 7.

Hospital Care

Hospital care for patients with acute exacerbations of COPD should be optimized by:

• Determining the appropriate level of care based on the initial severity and response to initial medical treatment 4.
• Providing care in the ICU for severe cases 4.
• Shortening hospital stay by non-invasive treatments 4.
• Implementing care coordination to improve the effectiveness of care for patients with COPD exacerbation 7.