What is the treatment for Chronic Obstructive Pulmonary Disease (COPD) exacerbation in an outpatient department (OPD) setting?

From the Guidelines

For outpatient treatment of COPD exacerbation, a short course of oral corticosteroids and antibiotics, when indicated, is recommended, in addition to increased doses of inhaled bronchodilators, to minimize the negative impact of the current exacerbation and prevent subsequent events. The treatment approach should prioritize reducing airway inflammation, improving bronchodilation, and addressing potential bacterial triggers. According to the European Respiratory Society/American Thoracic Society guideline 1, a short course (⩽14 days) of oral corticosteroids is suggested for ambulatory patients with an exacerbation of COPD, with a conditional recommendation and very low quality of evidence. Additionally, the administration of antibiotics is suggested for ambulatory patients with an exacerbation of COPD, with a conditional recommendation and moderate quality of evidence 1. The Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1 also recommends short-acting inhaled β2-agonists, with or without short-acting anticholinergics, as the initial bronchodilators to treat an acute exacerbation, and systemic corticosteroids to improve lung function and shorten recovery time. Some key points to consider in the treatment regimen include:

• Increased doses of inhaled bronchodilators, such as a short-acting beta-2 agonist like albuterol (2-4 puffs every 4-6 hours as needed) and a short-acting anticholinergic like ipratropium (2-4 puffs every 4-6 hours as needed)
• Oral prednisone 40 mg daily for 5 days
• Antibiotics, such as amoxicillin/clavulanate 875/125 mg twice daily for 5-7 days, or doxycycline 100 mg twice daily for 5-7 days if penicillin-allergic, if signs of bacterial infection are present
• Ensuring the patient has a spacer device for proper inhaler technique
• Considering home oxygen therapy for patients with significant hypoxemia (SpO2 < 88%)
• Educating the patient on proper inhaler use, the importance of completing the full course of medications, and when to seek emergency care (worsening breathlessness, chest pain, fever, or altered mental status)
• Scheduling a follow-up appointment within 1-2 weeks to assess response to treatment. This treatment approach is based on the most recent and highest quality evidence available, prioritizing morbidity, mortality, and quality of life as the outcome, and aims to manage symptoms and reduce the risk of hospitalization.

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).

The treatment for Chronic Obstructive Pulmonary Disease (COPD) exacerbation in an outpatient department (OPD) setting may include:

• Tiotropium 5 mcg inhalation spray to reduce the number of COPD exacerbations
• Antibiotics and/or systemic steroids as needed, based on the definition of exacerbations
• Hospitalization if necessary, based on the severity of the exacerbation 2

From the Research

Treatment for COPD Exacerbation in OPD Setting

• The treatment for Chronic Obstructive Pulmonary Disease (COPD) exacerbation in an outpatient department (OPD) setting typically involves the use of systemic corticosteroids, such as oral prednisone, to reduce inflammation and improve lung function 3.
• A study published in 1996 found that treatment with prednisone resulted in a more rapid improvement in arterial PO2, alveolar-arterial oxygen gradient, FEV1, and peak expiratory flow, as well as fewer treatment failures and improved subjective dyspnea 3.
• The optimal duration of corticosteroid therapy for COPD exacerbations is still a topic of debate, with some studies suggesting that shorter courses of treatment (5-7 days) may be sufficient, while others recommend longer courses (10-14 days) 4, 5, 6.
• A Cochrane review published in 2009 found that systemic corticosteroids significantly reduced treatment failure and the need for additional medical treatment, shortened hospital stay, and improved lung function and dyspnea, but increased the risk of adverse events, such as hyperglycemia 7.
• The use of corticosteroids in the treatment of COPD exacerbations is supported by multiple studies, which have consistently shown that they improve outcomes and reduce the risk of treatment failure 3, 4, 5, 6, 7.

Key Findings

• Systemic corticosteroids are effective in reducing treatment failure and improving lung function and dyspnea in patients with COPD exacerbations 3, 7.
• The optimal duration of corticosteroid therapy is still uncertain, with some studies suggesting that shorter courses may be sufficient 4, 5, 6.
• Corticosteroids increase the risk of adverse events, such as hyperglycemia, and the optimal dose and length of treatment need to be better defined 7.

Corticosteroid Therapy

• Oral prednisone is a commonly used corticosteroid for the treatment of COPD exacerbations 3.
• The dose and duration of corticosteroid therapy may vary depending on the severity of the exacerbation and the patient's response to treatment 4, 5, 6.
• Corticosteroids should be used in conjunction with other treatments, such as bronchodilators and antibiotics, as needed 7.