What is the treatment for acute wheezing in a patient with severe Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

The treatment for acute wheezing in a patient with severe COPD should prioritize short-acting inhaled bronchodilators, such as short-acting β-agonists, with or without short-acting anticholinergics, as the initial therapy, as recommended by the 2017 GOLD report 1. The primary goal is to relieve bronchospasm and reduce airway inflammation.

• Short-acting bronchodilators, such as albuterol (salbutamol) 2.5-5mg via nebulizer or 4-8 puffs via metered-dose inhaler with spacer, can be administered every 20 minutes for up to 1 hour, as needed.
• Ipratropium bromide 0.5mg via nebulizer or 4-8 puffs (20-40mcg per puff) via inhaler can be added to the treatment regimen, as it has been shown to be effective in combination with short-acting β-agonists. Systemic corticosteroids, such as prednisone 40-60mg orally daily for 5-7 days, should be administered promptly to reduce airway inflammation, as recommended by the 2017 GOLD report 1.
• The duration of systemic corticosteroid therapy should not exceed 5-7 days, as prolonged use can increase the risk of adverse effects. Supplemental oxygen should be provided to maintain oxygen saturation between 88-92%, as higher levels may suppress respiratory drive in COPD patients.
• Antibiotics, such as azithromycin 500mg on day 1 followed by 250mg daily for 4 days, should be considered if there are signs of infection, as they can help shorten recovery time and reduce the risk of early relapse. For severe exacerbations not responding to initial therapy, non-invasive positive pressure ventilation (NIPPV) may be necessary, as it has been shown to improve gas exchange, reduce the need for intubation, and decrease hospitalization duration, as recommended by the 2017 GOLD report 1.

From the FDA Drug Label

Ipratropium bromide is an anticholinergic (parasympatholytic) agent that, based on animal studies, appears to inhibit vagally mediated reflexes by antagonizing the action of acetylcholine, the transmitter agent released from the vagus nerve In controlled 12-week studies in patients with bronchospasm associated with chronic obstructive pulmonary disease (chronic bronchitis and emphysema) significant improvements in pulmonary function (FEV1 increases of 15% or more) occurred within 15 to 30 minutes, reached a peak in 1 to 2 hours, and persisted for periods of 4 to 5 hours in the majority of patients, with about 25% to 38% of the patients demonstrating increases of 15% or more for at least 7 to 8 hours. Combined therapy produced significant additional improvement in FEV1 and FVC

The treatment for acute wheezing in a patient with severe Chronic Obstructive Pulmonary Disease (COPD) is ipratropium bromide. Key points to consider are:

• Ipratropium bromide is an anticholinergic agent that helps to inhibit vagally mediated reflexes
• It can produce significant improvements in pulmonary function within 15 to 30 minutes
• Combined therapy with a beta adrenergic bronchodilator may produce additional improvement in FEV1 and FVC 2

From the Research

Treatment of Acute Wheezing in Patients with Severe COPD

The treatment of acute wheezing in patients with severe Chronic Obstructive Pulmonary Disease (COPD) involves the use of various pharmacological agents to manage symptoms and improve lung function.

• Bronchodilators: These are the primary treatment for acute wheezing in COPD patients. They work by relaxing the airway muscles, making it easier to breathe 3, 4, 5.
• Short-acting beta-2 agonists (SABAs): These are used for rescue from symptoms of COPD and have a rapid onset of action 3, 6.
• Long-acting beta-2 agonists (LABAs): These have a longer duration of action than SABAs and are used to improve lung function, health status, and symptom reduction in COPD patients 3, 7.
• Long-acting muscarinic antagonists (LAMAs): These are used to improve health outcomes in COPD patients and are often used in combination with LABAs 3, 7.
• Combination therapy: The use of combination therapy, such as LABA/LAMA or LABA/inhaled corticosteroids (ICS), is recommended for COPD patients who are not controlled by bronchodilator monotherapy 3, 7.

Management of Acute Exacerbations

The management of acute exacerbations of COPD involves the use of:

• Short-acting bronchodilators: Such as albuterol or ipratropium, to relieve acute symptoms 4, 5.
• Systemic corticosteroids: To reduce airway inflammation and improve lung function 7.
• Antibiotics: To treat any underlying bacterial infections 7.

Patient-Specific Treatment

The choice of treatment for acute wheezing in COPD patients should be individualized based on the patient's disease stage, response to treatment, and medical history 3, 7.