What is the management for acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

Management of Acute Exacerbation of COPD

The management of acute exacerbation of COPD requires prompt treatment with short-acting bronchodilators, systemic corticosteroids, and antibiotics when indicated to minimize negative impact on morbidity and mortality. 1

Definition and Classification

An acute exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy. Key symptoms include:

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence
• Increased cough and wheeze 1

COPD exacerbations are classified as:

• Mild: Treated with short-acting bronchodilators only
• Moderate: Treated with short-acting bronchodilators plus antibiotics and/or oral corticosteroids
• Severe: Requires hospitalization or emergency room visit; may be associated with acute respiratory failure 1

Pharmacological Management

1. Bronchodilators

• Short-acting bronchodilators are the initial treatment of choice for all exacerbations:
  • Short-acting β2-agonists (SABA) like albuterol
  • With or without short-acting anticholinergics (SAMA) like ipratropium 1
  • Can be delivered via metered-dose inhalers with spacers or nebulizers (equally effective, though nebulizers may be easier for sicker patients) 1

2. Systemic Corticosteroids

• Systemic corticosteroids should be prescribed for all patients with acute exacerbations of COPD to:
  • Improve lung function (FEV1)
  • Improve oxygenation
  • Shorten recovery time
  • Reduce hospitalization duration
  • Reduce risk of clinical failure 1
• Dosing recommendation: 40 mg prednisone daily for 5 days 1
• Oral administration is equally effective as intravenous administration 1
• Corticosteroids may be less effective in patients with lower blood eosinophil levels 1

3. Antibiotics

• Antibiotics should be prescribed for patients with:
  • All three cardinal symptoms (increased dyspnea, sputum volume, and sputum purulence)
  • Two cardinal symptoms if increased sputum purulence is one of them
  • Severe exacerbations requiring mechanical ventilation 1
• Antibiotics reduce:
  • Risk of short-term mortality
  • Treatment failure
  • Sputum purulence 1
• Antibiotic choice should be based on:
  • Local resistance patterns
  • Patient history and preferences
  • Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 3
• Duration: 5-7 days of treatment is recommended 1

4. Oxygen Therapy

• Supplemental oxygen should be provided to maintain oxygen saturation of 88-92% 1
• Careful titration is needed to avoid carbon dioxide retention

5. Ventilatory Support

• Noninvasive ventilation (NIV) should be the first mode of ventilation in patients with acute respiratory failure who have no absolute contraindication 1
• NIV improves:
  • Gas exchange
  • Reduces work of breathing
  • Decreases need for intubation
  • Decreases hospitalization duration
  • Improves survival 1

Treatment Setting Decision

The decision between outpatient and inpatient management depends on:

• Severity of the exacerbation
• Severity of underlying COPD
• Presence of comorbidities
• Availability of home support

More than 80% of exacerbations can be managed on an outpatient basis 1

Important Considerations

What to Avoid

• Methylxanthines (e.g., theophylline) are not recommended due to increased side effect profiles 1

Post-Exacerbation Management

• Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 1
• Appropriate measures for exacerbation prevention should be initiated:
  • Smoking cessation
  • Vaccination (influenza, pneumococcal)
  • Pulmonary rehabilitation when stable
  • Regular follow-up 1

Differential Diagnosis

Always consider alternative diagnoses that may mimic COPD exacerbations:

• Acute coronary syndrome
• Worsening congestive heart failure
• Pulmonary embolism
• Pneumonia 1

Follow-up

• Schedule follow-up within 2 weeks after discharge
• Monitor symptoms, lung function, and response to therapy
• Adjust maintenance therapy as needed
• Assess inhaler technique and adherence 1