From the Guidelines
Steroid and antibiotic treatment should be initiated promptly in a 92-year-old COPD patient experiencing an exacerbation, characterized by worsened shortness of breath, increased cough, changes in sputum (increased volume, thickness, or purulence), chest tightness, and decreased exercise tolerance. The symptoms of a COPD exacerbation include:
- Increased dyspnea
- Increased frequency and severity of cough
- Increased sputum production
- Changes in sputum color or consistency
- Chest tightness
- Decreased exercise tolerance
According to the most recent and highest quality study 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.
For steroids, oral prednisone 40mg daily for 5 days is typically recommended 1. Antibiotic therapy should be started when there is increased sputum purulence plus either increased dyspnea or increased sputum volume, with amoxicillin-clavulanate 875/125mg twice daily for 5-7 days being a common choice, or alternatives like doxycycline 100mg twice daily or azithromycin 500mg on day 1 followed by 250mg daily for 4 days if penicillin allergy exists 1.
In elderly patients, close monitoring for side effects is essential, including checking for steroid-induced hyperglycemia, mood changes, and sleep disturbances, as well as antibiotic-related gastrointestinal issues or allergic reactions 1. Early intervention is crucial in this age group as exacerbations can rapidly progress to respiratory failure, with treatment decisions based on symptom severity, previous exacerbation patterns, and known pathogens from prior cultures. Oxygen supplementation should be provided to maintain saturation between 88-92%, and bronchodilator therapy should be optimized during the exacerbation 1.
It is also important to note that patients with COPD susceptible to frequent exacerbations (defined as two or more exacerbations per year) have worse health status and morbidity than patients with less-frequent exacerbations 1. Therefore, prevention or reduction of severity of subsequent exacerbation episodes is also a goal for many management and prevention strategies.
From the Research
Symptoms of COPD Exacerbation
The symptoms of a COPD exacerbation include:
- Increased dyspnea (shortness of breath) 2
- Increased cough 2
- Increased sputum production 2
- Increased sputum purulence 2
- Acute worsening of symptoms, sometimes accompanied by increased cough, sputum volume, and/or sputum purulence 2
Initiating Steroid and Antibiotic Treatment
There is no specific guideline on when to initiate steroid and antibiotic treatment in a 92-year-old patient with frequent COPD exacerbations. However, the following points can be considered:
- COPD exacerbations are mainly triggered by respiratory infections and environmental factors 3
- Pharmacological interventions such as inhaled steroids, long-acting bronchodilators, and their combinations are effective in reducing exacerbation frequency and severity 4
- The treatment of COPD exacerbations should be individualized based on the patient's phenotype and risk factors 5
- The goals of COPD treatment include recognizing the impact of both symptoms and exacerbations on patients' lives and considering optimal patient-focused management 3
Management of Frequent Exacerbations
For patients with frequent COPD exacerbations, the following management strategies can be considered:
- Maximizing bronchodilation as an initial strategy to reduce exacerbation risk 5
- Adding inhaled corticosteroids (ICS) to a LABA/LAMA combination in exacerbating patients who have an asthma-COPD overlap syndrome or high blood eosinophil counts 5
- Considering treatment with a phosphodiesterase (PDE)-4 inhibitor (roflumilast) or high-dose mucolytic agents in exacerbators with chronic bronchitis 5
- Adding mucolytic agents or a macrolide antibiotic (e.g. azithromycin) in patients who experience frequent bacterial exacerbations and/or bronchiectasis 5