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

From the Guidelines

Management of acute exacerbation of COPD requires prompt intervention with bronchodilators, systemic corticosteroids, and antibiotics when appropriate, as recommended by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1. The goal of treatment is to minimize the negative impact of the current exacerbation and prevent subsequent events 1.

Initial Treatment

Short-acting bronchodilators like albuterol (2.5-5 mg via nebulizer or 4-8 puffs via MDI every 4-6 hours) and ipratropium (0.5 mg via nebulizer or 4-8 puffs via MDI every 4-6 hours) should be administered immediately to relieve bronchospasm 1. Systemic corticosteroids, such as prednisone 40 mg daily for 5 days, reduce airway inflammation and speed recovery 1.

Antibiotic Therapy

Antibiotics are indicated when there are signs of bacterial infection (increased sputum purulence, volume, or dyspnea); commonly used options include amoxicillin-clavulanate 875/125 mg twice daily, doxycycline 100 mg twice daily, or azithromycin 500 mg on day 1 followed by 250 mg daily for 4 days 1.

Oxygen Therapy and Ventilation

Supplemental oxygen should be provided to maintain oxygen saturation between 88-92%, as excessive oxygen can worsen hypercapnia in COPD patients 1. For severe exacerbations, non-invasive positive pressure ventilation (NIPPV) may be necessary to reduce work of breathing and avoid intubation 1.

Prevention of Future Exacerbations

After 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. Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 1. The pathophysiology involves worsened airflow limitation due to increased inflammation, mucus hypersecretion, and air trapping, which explains why bronchodilators and anti-inflammatory medications form the cornerstone of treatment.

Key points to consider in the management of acute exacerbation of COPD include:

• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, as initial bronchodilators 1
• Systemic corticosteroids to improve lung function and shorten recovery time 1
• Antibiotics when indicated to shorten recovery time and reduce the risk of early relapse 1
• NIV as the first mode of ventilation used to treat acute respiratory failure 1
• Education on proper inhaler technique, smoking cessation counseling, and review of maintenance therapy to prevent future exacerbations 1

From the FDA Drug Label

The effect of tiotropium 5 mcg inhalation spray on exacerbations was evaluated in three 48-week randomized, double-blind, placebo-controlled clinical trials that included COPD exacerbations as the primary endpoint Exacerbations of COPD were defined as a complex of lower respiratory events/symptoms (increase or new onset) related to the underlying COPD, with duration of three days or more, requiring a prescription of antibiotics and/or systemic steroids and/or hospitalization In a pooled analysis of the first two trials, tiotropium 5 mcg significantly reduced the number of COPD exacerbations compared to placebo with a rate ratio of 0.78 (95% CI 0.67,0.92). In the third trial, tiotropium 5 mcg delayed the time to first COPD exacerbation compared to placebo with a hazard ratio of 0.69 (95% CI 0.63,0. 77). STIOLTO RESPIMAT treatment did not demonstrate superiority to tiotropium 5 mcg inhalation spray for the primary endpoint, the annualized rate of moderate to severe COPD exacerbations, with a rate ratio of 0.93 (99% CI, 0.85-1.02, p=0.0498).

The management of acute exacerbation of COPD may involve the use of tiotropium 5 mcg, as it has been shown to:

• Reduce the number of COPD exacerbations compared to placebo
• Delay the time to first COPD exacerbation compared to placebo However, STIOLTO RESPIMAT did not demonstrate superiority to tiotropium 5 mcg in reducing the annualized rate of moderate to severe COPD exacerbations 2. Key points:
• Tiotropium 5 mcg may be used to reduce the number of COPD exacerbations
• STIOLTO RESPIMAT did not demonstrate superiority to tiotropium 5 mcg in reducing COPD exacerbations
• The use of tiotropium 5 mcg or STIOLTO RESPIMAT should be based on individual patient needs and medical history 2.

From the Research

Management of Acute Exacerbation of COPD

• The management of acute exacerbation of COPD involves pharmacological and non-pharmacological treatments 3, 4.
• Pharmacological treatments include bronchodilators, corticosteroids, and antibiotics 3, 4.
• Bronchodilators such as albuterol and ipratropium bromide can be used alone or in combination to improve airflow in patients with COPD 5, 6.
• The combination of ipratropium and albuterol is more effective than either agent alone in improving lung function in patients with COPD 5.
• Corticosteroids are beneficial in reducing the severity of exacerbations and improving outcomes 3, 4.
• Antibiotics are recommended for patients with severe exacerbations, particularly those requiring hospitalization 3, 4.

Non-Pharmacological Treatments

• Non-invasive ventilation (NIV) is a standard therapy for patients with COPD exacerbation and is supported by clinical practice guidelines 4, 7.
• Oxygen therapy should be titrated to an SpO2 of 88-92% to improve outcomes 7.
• High-flow nasal cannula (HFNC) oxygen therapy may be beneficial, but further prospective studies are needed to confirm its efficacy 4.
• Pulmonary rehabilitation is recommended as part of the management of COPD exacerbations, as it improves feasibility and safety 4.

Treatment Goals

• The goal of treatment is to minimize the negative impact of the current exacerbation and prevent subsequent events, such as relapse or readmission to hospital 4.
• Treatment should be individualized based on the severity of the exacerbation, the patient's underlying disease, and their response to treatment 3, 4.
• Care coordination and evidence-based practices can improve the effectiveness of care for patients with COPD exacerbation 7.