What is the treatment for Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

Treatment for COPD exacerbation should involve a multi-faceted approach, including bronchodilators, systemic corticosteroids, and antibiotics when indicated, to reduce inflammation, improve airflow, and prevent complications, as recommended by the most recent guidelines 1. The cornerstone of treatment includes bronchodilators, specifically short-acting beta-agonists (SABAs) like albuterol (2-4 puffs every 4-6 hours) and short-acting muscarinic antagonists (SAMAs) like ipratropium (2-4 puffs every 4-6 hours), which work by relaxing the airway muscles to improve breathing.

• Systemic corticosteroids, typically prednisone 40mg daily for 5 days, are essential to reduce inflammation in the airways, as evidenced by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.
• For patients with signs of bacterial infection (increased sputum purulence, volume, or fever), antibiotics are recommended, such as amoxicillin-clavulanate 875/125mg twice daily, doxycycline 100mg twice daily, or azithromycin 500mg on day 1 followed by 250mg daily for 4 days.
• Supplemental oxygen should be provided to maintain oxygen saturation above 88-92%, and in severe cases, non-invasive ventilation (NIV) may be necessary, as suggested by the American Family Physician guideline 1. After the acute phase, patients should transition back to their maintenance therapy, which often includes long-acting bronchodilators and possibly inhaled corticosteroids.
• Prevention of future exacerbations involves smoking cessation, pulmonary rehabilitation, vaccination against influenza and pneumococcal disease, and proper inhaler technique education, as recommended by the American College of Chest Physicians and Canadian Thoracic Society guideline 1. These interventions target the underlying pathophysiology of COPD exacerbations, which involves increased inflammation, mucus hypersecretion, and bronchoconstriction, and are supported by the most recent and highest quality studies, including the 2021 pharmacologic management of COPD exacerbations guideline from the American Academy of Family Physicians 1.

From the FDA Drug Label

Wixela Inhub® 250/50 is also indicated to reduce exacerbations of COPD in patients with a history of exacerbations If shortness of breath occurs in the period between doses, an inhaled, short-acting beta2-agonist should be taken for immediate relief

Treatment of COPD Exacerbation:

• The drug label does not provide a specific treatment regimen for COPD exacerbation.
• However, it is indicated that Wixela Inhub® 250/50 can reduce exacerbations of COPD in patients with a history of exacerbations.
• For immediate relief of shortness of breath, an inhaled, short-acting beta2-agonist should be taken. 2

From the Research

COPD Exacerbation Treatment

• COPD exacerbation is characterized by an increase in symptoms such as dyspnea, cough, and sputum production that worsens over a period of 2 weeks 3
• Targeted O2 therapy improves outcomes and should be titrated to an SpO2 of 88-92% 3
• Inhaled short-acting bronchodilators can be provided by nebulizer, pressurized metered-dose inhaler, or dry powder inhaler 3
• Noninvasive ventilation (NIV) is standard therapy for patients who present with COPD exacerbation and is supported by clinical practice guidelines 3

Medication Regimens

• The pharmacotherapy of COPD exacerbations includes bronchodilators, corticosteroids, and antibiotics 4
• Strong evidence exists for the benefit of corticosteroids for exacerbations and of antibiotics in the acute hospital setting 4
• Combination therapy with albuterol and ipratropium bromide provides better improvement in airflow than either component alone 5, 6
• Tiotropium can be used as an alternative to the ipratropium/albuterol combination, with at least equivalent bronchodilation during daytime hours and superior bronchodilation during early morning hours 7

Management of COPD Exacerbation

• Management of auto-PEEP is the priority in mechanically ventilated patients with COPD, achieved by reducing airway resistance and decreasing minute ventilation 3
• Trigger asynchrony and cycle asynchrony should be addressed to improve patient-ventilator interaction 3
• Patients with COPD should be extubated to NIV 3
• Care coordination can improve the effectiveness of care for patients with COPD exacerbation 3