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

From the Guidelines

The primary management for acute exacerbation of COPD involves a multifaceted approach to reduce morbidity, mortality, and improve quality of life, as outlined in the most recent guideline from the American Family Physician 1. The management strategy includes:

• Bronchodilators: Increase the dose and frequency of short-acting beta-2 agonists (e.g., albuterol 2-4 puffs every 4-6 hours) and anticholinergics (e.g., ipratropium 2-4 puffs every 4-6 hours) to improve bronchodilation and reduce symptoms.
• Systemic corticosteroids: Prednisone 40mg orally daily for 5 days to reduce airway inflammation, as recommended by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 1.
• Antibiotics: If increased sputum purulence or volume, prescribe a 5-7 day course of antibiotics (e.g., amoxicillin/clavulanate, doxycycline, or azithromycin) to treat potential bacterial infections.
• Oxygen therapy: Maintain oxygen saturation between 88-92% to support oxygenation while minimizing the risk of hypercapnic respiratory failure, as guided by the British Thoracic Society 1.
• Non-invasive ventilation: Consider for patients with respiratory acidosis (pH <7.35) or severe dyspnea to reduce the risk of further deterioration and need for intubation. Additional measures include:

• Assess and treat any underlying triggers (e.g., infections, heart failure)
• Ensure proper inhaler technique
• Consider chest physiotherapy for sputum clearance
• Evaluate need for hospital admission based on severity This approach aims to reduce airway inflammation, improve bronchodilation, treat potential infections, and support oxygenation, ultimately preventing further deterioration and reducing the risk of hospitalization.

From the Research

Management of Acute Exacerbation of COPD

The management of acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) involves several key components, including:

• Increasing the dosage of inhaled short-acting bronchodilators, such as ipratropium and albuterol, to relieve dyspnea 2
• Using oral corticosteroids, which are likely beneficial, especially for patients with purulent sputum 2
• Administering antibiotics to reduce the risk of treatment failure and mortality in moderately or severely ill patients, with the choice of antibiotic guided by local resistance patterns and the patient's recent history of antibiotic use 2
• Providing supplemental oxygen, with a target oxygen saturation of 88-92% 3
• Using noninvasive positive pressure ventilation (NIV) or invasive mechanical ventilation in patients with worsening acidosis or hypoxemia 2

Treatment Approaches

Different treatment approaches may be used, including:

• Targeted O2 therapy, which improves outcomes and should be titrated to an SpO2 of 88-92% 3
• Inhaled short-acting bronchodilators, which can be provided by nebulizer, pressurized metered-dose inhaler (pMDI), pMDI with spacer or valved holding chamber, soft mist inhaler, or dry powder inhaler 3
• NIV, which is standard therapy for patients who present with COPD exacerbation and is supported by clinical practice guidelines 3
• Management of auto-PEEP, which is the priority in mechanically ventilated patients with COPD, achieved by reducing airway resistance and decreasing minute ventilation 3

Care Coordination and Patient Education

Care coordination and patient education are also important components of managing COPD exacerbations, including:

• Ensuring that patients understand and can act on exacerbations through a supported self-management plan 4
• Providing prompt treatment, balanced by careful antibiotic and corticosteroid stewardship 4
• Reducing exacerbation frequency through long-term COPD care, including chronic maintenance pharmacotherapy, influenza and pneumonia vaccinations, and pulmonary rehabilitation 5