What is the treatment for chronic obstructive pulmonary disease (COPD) exacerbation in an inpatient setting?

From the Guidelines

The treatment for COPD exacerbation in an inpatient setting should prioritize a multi-faceted approach, including short-acting bronchodilators, systemic corticosteroids, antibiotics when indicated, and supplemental oxygen titrated to maintain oxygen saturation between 88-92%. This approach is supported by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1, which recommends short-acting inhaled β2-agonists, with or without short-acting anticholinergics, as the initial bronchodilators to treat an acute exacerbation. Systemic corticosteroids, such as prednisone 40mg daily, are also recommended to improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1.

When considering the use of antibiotics, it is essential to identify signs of bacterial infection, and options may include amoxicillin-clavulanate, azithromycin, or doxycycline 1. Supplemental oxygen should be used judiciously, with a target saturation range of 88-92% to avoid worsening hypercapnia in COPD patients 1. Non-invasive positive pressure ventilation (NIPPV) should be considered for patients with respiratory acidosis (pH <7.35) or severe dyspnea, as recommended by the European Respiratory Society/American Thoracic Society guideline 1.

Key considerations in the management of COPD exacerbations include:

• Monitoring for hypercapnic respiratory failure with respiratory acidosis
• Avoiding excessive oxygen use
• Targeting an oxygen saturation range of 88-92% in patients with a history of hypercapnic respiratory failure
• Rechecking blood gases after 30-60 minutes to assess for rising PCO2 or falling pH
• Initiating NIV with targeted oxygen therapy if respiratory acidosis persists despite standard medical management 1.

By prioritizing these interventions, healthcare providers can effectively manage COPD exacerbations, reduce morbidity and mortality, and improve quality of life for patients.

From the FDA Drug Label

Adult PatientsAcute Bacterial Exacerbations of Chronic Obstructive Pulmonary Disease In a randomized, double-blind controlled clinical trial of acute exacerbation of chronic bronchitis (AECB), azithromycin (500 mg once daily for 3 days) was compared with clarithromycin (500 mg twice daily for 10 days). The primary endpoint of this trial was the clinical cure rate at Day 21 to 24 For the 304 patients analyzed in the modified intent to treat analysis at the Day 21 to 24 visit, the clinical cure rate for 3 days of azithromycin was 85% (125/147) compared to 82% (129/157) for 10 days of clarithromycin

The treatment for COPD exacerbation in an inpatient setting may include azithromycin (500 mg once daily for 3 days) as it has shown a clinical cure rate of 85% in a randomized, double-blind controlled clinical trial 2.

• Key points:
  • Azithromycin has been studied for the treatment of acute bacterial exacerbations of chronic obstructive pulmonary disease (COPD)
  • The clinical cure rate for azithromycin was 85% in the modified intent to treat analysis at the Day 21 to 24 visit
  • Ipratropium bromide has not been adequately studied as a single agent for the relief of bronchospasm in acute COPD exacerbation, and may not be the preferred initial therapy in this situation 3

From the Research

Treatment Overview

• The treatment for chronic obstructive pulmonary disease (COPD) exacerbation in an inpatient setting typically involves bronchodilator therapy, glucocorticoids, and antibiotics 4.
• Bronchodilators, such as beta(2)-adrenoceptor agonists and anticholinergic agents, are usually given first to produce a rapid response 4.
• Glucocorticoids can accelerate recovery, but a longer treatment duration may be required 4.

Pharmacologic Therapy

• Current guidelines recommend inhaled pharmacologic therapy as the preferred route of administration for treating COPD 5.
• Bronchodilators (β2-agonists and antimuscarinics) are the mainstay of pharmacologic therapy in patients with COPD, with long-acting agents recommended for patients with moderate to severe symptoms or those who are at a higher risk for COPD exacerbations 5.
• Nebulized drug delivery can provide benefits similar to drugs delivered by handheld inhalers in both symptom relief and improved quality of life 5.

Corticosteroid Treatment

• Systemic corticosteroids, such as prednisolone, are effective in treating COPD exacerbations, and oral administration is not inferior to intravenous (IV) administration 6.
• A study found that oral prednisolone (60 mg) was as effective as IV prednisolone in reducing treatment failure and improving clinical outcomes in patients hospitalized for COPD exacerbations 6.

Bronchodilator Treatment

• Bronchodilators, including long-acting β2-agonists (LABAs) and long-acting anti-muscarinic agents (LAMAs), can reduce COPD symptoms and prevent exacerbations 7.
• A study compared the effects of ipratropium bromide and metaproterenol sulfate in acute exacerbations of COPD and found that both medications were effective in improving pulmonary function, but ipratropium may be a safer choice as it did not cause a decline in blood oxygenation 8.