What are the management options for an inpatient with Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

Management of an inpatient COPD exacerbation requires prompt treatment with bronchodilators, systemic corticosteroids, and antibiotics when indicated, as well as consideration of non-invasive mechanical ventilation and supplemental oxygen to reduce morbidity, mortality, and improve quality of life. The treatment approach should be guided by the severity of the exacerbation and the presence of comorbidities.

Treatment Approach

• Start with short-acting bronchodilators such as albuterol 2.5-5mg via nebulizer or 4-8 puffs via MDI with spacer every 1-4 hours as needed, and ipratropium 0.5mg via nebulizer or 4-8 puffs via MDI every 4-6 hours 1.
• Administer systemic corticosteroids, typically prednisone 40mg daily orally for 5 days or methylprednisolone 40-60mg IV daily if the patient cannot take oral medications, as suggested by the European Respiratory Society/American Thoracic Society guideline 1.
• Antibiotics should be given if there are signs of bacterial infection (increased sputum purulence, volume, or fever); options include azithromycin 500mg on day 1 followed by 250mg daily for 4 days, amoxicillin-clavulanate 875/125mg twice daily for 5-7 days, or doxycycline 100mg twice daily for 5-7 days.
• Supplemental oxygen should be provided to maintain oxygen saturation between 88-92% 1.
• Consider non-invasive positive pressure ventilation (NIPPV) for patients with respiratory acidosis (pH < 7.35) or severe dyspnea, as recommended by the European Respiratory Society/American Thoracic Society guideline 1.

Additional Considerations

• Assess for comorbidities that may exacerbate COPD symptoms, such as heart failure or pulmonary embolism.
• Consider a home-based management programme (hospital-at-home) for patients with COPD exacerbations who present to the emergency department or hospital, as suggested by the European Respiratory Society/American Thoracic Society guideline 1.
• Pulmonary rehabilitation should be initiated within 3 weeks after hospital discharge for patients who are hospitalised with a COPD exacerbation, as suggested by the European Respiratory Society/American Thoracic Society guideline 1.

From the FDA Drug Label

The 2 exacerbation trials with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg were identical trials designed to evaluate the effect of fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg and salmeterol 50 mcg, each given twice daily, on exacerbations of COPD over a 12-month period In both trials, treatment with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg resulted in a significantly lower annual rate of moderate/severe COPD exacerbations compared with salmeterol Subjects treated with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg also had a significantly lower annual rate of exacerbations requiring treatment with oral corticosteroids compared with subjects treated with salmeterol

The management options for an inpatient with Chronic Obstructive Pulmonary Disease (COPD) exacerbation include:

• Treatment with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg twice daily, which has been shown to reduce the annual rate of moderate/severe COPD exacerbations and exacerbations requiring treatment with oral corticosteroids compared to salmeterol 50 mcg alone 2
• Use of short-acting beta2-agonist for immediate relief of symptoms, such as shortness of breath, that arise between doses of maintenance medication 2
• Consideration of additional therapeutic options, such as replacing the current strength of Wixela Inhub with a higher strength, adding additional ICS, or initiating oral corticosteroids, if a previously effective dosage regimen fails to provide adequate improvement in asthma control or COPD symptoms 2

From the Research

Management Options for COPD Exacerbation

The management of COPD exacerbation involves several key components, including:

• Pharmacological interventions:
  • Inhaled bronchodilators, such as beta-adrenoceptor agonists and anticholinergics, to optimize lung function 3
  • Systemic corticosteroids to hasten recovery and reduce relapse rates 3, 4
  • Antibacterials to decrease morbidity and mortality in severe exacerbations 3
• Oxygen therapy:
  • Targeted O2 therapy to improve outcomes, titrated to an SpO2 of 88-92% 5, 6, 7
  • Caution against high-concentration oxygen therapy, which may increase mortality risk 7
• Non-invasive ventilation:
  • Standard therapy for patients with COPD exacerbation and hypercapnic respiratory failure 3, 4, 5
• Other therapies:
  • Venous thromboembolism prophylaxis, immunizations, and counseling for smoking cessation 4
  • Pulmonary rehabilitation and case management programs to reduce exacerbation risk 3

Adjuvant Components of Care

Additional components of care for patients with COPD exacerbation include:

• Early consideration of non-invasive ventilation 4
• Management of auto-PEEP in mechanically ventilated patients 5
• Care coordination to improve the effectiveness of care 5
• Evidence-based practices to improve outcomes in patients with COPD exacerbation 5