From the Guidelines
The management of a COPD exacerbation involves prompt treatment with bronchodilators, corticosteroids, and antibiotics when appropriate, as recommended by the most recent guidelines from the American Family Physician in 2021 1. The goals for management of acute exacerbations of COPD include symptom resolution and recovery from the exacerbation episode via improving airflow and gas exchange in addition to reducing lung inflammation. Some key points to consider in the management of COPD exacerbations include:
- Short-acting bronchodilators like albuterol and ipratropium should be administered immediately to relieve bronchospasm, as suggested by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.
- Systemic corticosteroids, such as prednisone 40 mg daily for 5 days, reduce airway inflammation and speed recovery, as recommended by the European Respiratory Society/American Thoracic Society guideline in 2017 1.
- Antibiotics should be given when there are signs of bacterial infection, such as increased sputum purulence or volume, as suggested by the same guideline 1.
- Supplemental oxygen should be provided to maintain oxygen saturation between 88-92%, as higher levels may suppress respiratory drive in some COPD patients.
- For severe exacerbations, non-invasive ventilation (NIV) like BiPAP may be necessary to reduce work of breathing and prevent intubation, as recommended by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1. Patients should be monitored for response to therapy, with vital signs, oxygen saturation, and symptom assessment. Following the acute phase, a comprehensive discharge plan should include inhaler technique education, smoking cessation counseling, pulmonary rehabilitation referral, and optimization of maintenance therapy to prevent future exacerbations, as recommended by the American Family Physician in 2021 1.
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 management plan for a COPD exacerbation may include the use of 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 compared to clarithromycin in the treatment of acute exacerbation of chronic bronchitis.
- The clinical cure rate for azithromycin was 85% compared to 82% for clarithromycin.
- Azithromycin may be considered as part of the management plan for COPD exacerbation. However, it is essential to note that ipratropium bromide as a single agent for the relief of bronchospasm in acute COPD exacerbation has not been adequately studied, and drugs with faster onset of action may be preferable as initial therapy in this situation 3.
From the Research
Management Plan for COPD Exacerbation
The management plan for a COPD exacerbation involves several key components, including:
- Administration of short-acting bronchodilators to reverse bronchoconstriction, restore lung volumes, and relieve breathlessness 4
- Use of long-acting bronchodilators as first-line agents for maintenance therapy in patients with moderate and severe disease and those with daily symptoms 5
- Combination of bronchodilators of different classes for patients whose symptoms are not sufficiently controlled by a single bronchodilator 5
- Noninvasive ventilation for patients who require ventilatory support 6
- Oral corticosteroids, such as prednisone, to accelerate recovery and reduce treatment failure rate 7
Treatment Modalities
Treatment modalities for COPD exacerbation are the same regardless of the site of treatment, and include:
- Inhaled pharmacologic therapy, with bronchodilators (β2-agonists and antimuscarinics) as the mainstay of treatment 8
- Nebulized drug delivery, which provides benefits similar to drugs delivered by handheld inhalers in both symptom relief and improved quality of life 8
- Oxygen therapy to improve arterial oxygenation and reduce the risk of respiratory failure
Monitoring and Evaluation
Monitoring and evaluation of patients with COPD exacerbation are crucial to assess treatment response and adjust the management plan as needed, including: