From the Guidelines
Acute exacerbation of COPD requires prompt treatment with bronchodilators, systemic corticosteroids, and often antibiotics to reduce morbidity, mortality, and improve quality of life. For immediate management, administer a short-acting bronchodilator like albuterol (2.5-5mg) via nebulizer or 4-8 puffs via MDI with spacer every 1-4 hours as needed, as recommended by the American Family Physician 1. Add ipratropium bromide (0.5mg nebulized or 4-8 puffs) for enhanced bronchodilation. Start oral prednisone 40mg daily for 5 days (no taper needed for short courses), as suggested by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1. If signs of infection are present (increased sputum purulence, fever), prescribe an antibiotic such as azithromycin 500mg on day 1, then 250mg daily for 4 more days, or doxycycline 100mg twice daily for 5-7 days, as recommended by the European Respiratory Society/American Thoracic Society guideline 1.
Key Interventions
- Supplemental oxygen should be provided to maintain oxygen saturation at 88-92% to reduce hypoxemia-related morbidity and mortality.
- Hospitalization is necessary for severe exacerbations with respiratory distress, significant hypoxemia, or failure to respond to initial therapy.
- Noninvasive ventilation (NIV) should be considered for patients with acute respiratory failure, as it improves gas exchange, reduces work of breathing, and decreases hospitalization duration, as recommended by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.
Prevention of Future Exacerbations
After the acute phase, review maintenance therapy, ensure proper inhaler technique, and consider pulmonary rehabilitation to prevent future exacerbations, as suggested by the European Respiratory Society/American Thoracic Society guideline 1. Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge to reduce the risk of future exacerbations.
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 recommended dose of azithromycin for acute bacterial exacerbations of chronic obstructive pulmonary disease (mild to moderate) is 500 mg QD × 3 days.
- The clinical cure rate for azithromycin was 85% at Day 21 to 24.
- Key pathogens and their corresponding clinical cure rates were:
- S. pneumoniae: 91%
- H. influenzae: 86%
- M catarrhalis: 92% 2
From the Research
Definition and Management of Acute Exacerbation of COPD
- Acute exacerbation of COPD (AECOPD) is defined as a sudden worsening of respiratory symptoms that requires additional therapy 3.
- The management of AECOPD aims to minimize the negative impact of the current exacerbation and prevent subsequent events, such as relapse or readmission to hospital 3, 4.
Pharmacological Treatments
- Inhaled bronchodilators, such as salbutamol and ipratropium bromide, are useful in AECOPD 5, 6.
- Corticosteroids, such as oral corticosteroids, are beneficial in reducing the risk of treatment failure and mortality 5, 6.
- Antibiotics are recommended for patients with purulent sputum or those who have inadequate symptom relief with bronchodilators and corticosteroids 5, 6.
Non-Pharmacological Treatments
- Oxygen therapy, including high flow nasal cannulae (HFNC) oxygen therapy, is used to improve outcomes in hypoxaemic patients 3, 5.
- Non-invasive mechanical ventilation (NIMV) is indicated in patients with worsening acidosis or hypoxemia 3, 5, 6.
- Pulmonary rehabilitation is recommended for patients with AECOPD, as it is feasible and safe 3, 4.
Emergency Department Management
- Routine emergency department (ED) care for AECOPD includes inhalations of short-acting bronchodilators and systemic steroids 7.
- Delayed ED treatment and long ED length-of-stay are associated with older age, lack of a coded diagnosis of COPD, and longer hospitalizations 7.
- Predictors for patients not receiving routine ED care include obesity and fever, while oxygen saturation <91% is an independent predictor for ED routine treatment 7.