What is the recommended management for outpatient chronic obstructive pulmonary disease (COPD) exacerbation?

From the Guidelines

The recommended management for outpatient COPD exacerbation includes short-acting bronchodilators, systemic corticosteroids, and antibiotics when indicated, as outlined in the most recent guideline from 2021 1. The management of outpatient COPD exacerbation should prioritize reducing airway inflammation, relieving bronchospasm, and addressing potential bacterial infections.

• Short-acting beta-agonists (such as albuterol 2.5 mg via nebulizer or 2-4 puffs via MDI every 4-6 hours) and anticholinergics (such as ipratropium 0.5 mg via nebulizer or 2-4 puffs via MDI every 4-6 hours) should be used to relieve bronchospasm, as recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report in 2017 1.
• Oral corticosteroids like prednisone 40 mg daily for 5 days are recommended to reduce airway inflammation and hasten recovery, with the duration of therapy not exceeding 5-7 days, as suggested by the GOLD report in 2017 1 and supported by the American College of Chest Physicians and Canadian Thoracic Society guideline in 2015 1.
• Antibiotics should be prescribed when patients exhibit increased sputum purulence along with either increased dyspnea or sputum volume; common regimens 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, typically for 5-7 days total, as indicated by the GOLD report in 2017 1.
• Patients should continue their maintenance inhalers during exacerbations, and oxygen supplementation may be necessary for patients with hypoxemia, aiming to maintain oxygen saturation between 88-92%, as part of comprehensive management.
• Patient education about proper inhaler technique, adherence to medication, and recognition of worsening symptoms is essential, along with follow-up within 1-2 weeks to assess response to treatment, emphasizing the importance of coordinated care between subspecialists and primary care physicians, as highlighted in the 2021 clinical practice guideline from the American Academy of Family Physicians 1.

From the Research

Outpatient COPD Exacerbation Management

The management of chronic obstructive pulmonary disease (COPD) exacerbations in an outpatient setting involves several key strategies.

• Increasing the dosage of inhaled short-acting bronchodilators is the first step in outpatient management, as stated in the study 2.
• Combining ipratropium and albuterol is beneficial in relieving dyspnea, according to the study 2 and further supported by the findings of 3, which demonstrated that the combination of these two agents is more effective than either alone in patients with COPD.
• Oral corticosteroids are likely beneficial, especially for patients with purulent sputum, as noted in 2.
• The use of antibiotics reduces the risk of treatment failure and mortality in moderately or severely ill patients, and their use should be guided by local resistance patterns and the patient's recent history of antibiotic use, as recommended in 2.

Pharmacologic Interventions

Pharmacologic management of COPD exacerbations includes:

• Bronchodilators: inhaled short-acting bronchodilators, such as albuterol and ipratropium, are used to relieve bronchospasm and improve lung function, as discussed in 2 and 3.
• Corticosteroids: oral corticosteroids are used to reduce airway inflammation, as mentioned in 2 and 4.
• Antibiotics: used to treat bacterial infections, such as purulent sputum, and should be chosen based on local resistance patterns and the patient's recent antibiotic use history, as stated in 2.

Non-Pharmacologic Interventions

Non-pharmacologic strategies to manage COPD exacerbations include:

• Pulmonary rehabilitation: a comprehensive program that includes exercise, education, and support to improve lung function and overall health, as discussed in 5 and 6.
• Patient education: teaching patients about their disease, medications, and self-management techniques to improve adherence and reduce exacerbations, as mentioned in 6.
• Multidisciplinary disease-management programs: a team-based approach that includes healthcare providers, patients, and families to provide comprehensive care and support, as discussed in 6.