What is the approach to managing an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

The acute management of COPD exacerbation involves prompt administration of bronchodilators, systemic corticosteroids, and antibiotics when indicated, with the goal of minimizing morbidity, mortality, and improving quality of life. The approach to managing an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) should prioritize interventions that reduce airway inflammation, improve bronchodilation, treat infectious triggers, and support gas exchange during the acute phase of exacerbation.

Key Interventions

• Short-acting bronchodilators should be given immediately, typically albuterol (salbutamol) 2.5-5mg via nebulizer or 4-8 puffs via MDI with spacer every 1-4 hours as needed, as recommended by 1 and 1.
• Ipratropium bromide 0.5mg nebulized or 4-8 puffs via MDI can be added for enhanced bronchodilation.
• Systemic corticosteroids should be started early, with prednisone 40mg daily for 5 days being a standard regimen, as supported by 1 and 1.
• Antibiotics are indicated when there are signs of bacterial infection (increased sputum purulence, volume, or dyspnea); commonly used options include amoxicillin-clavulanate 875/125mg twice daily, doxycycline 100mg twice daily, or azithromycin 500mg on day 1 followed by 250mg daily for 4 days, as suggested by 1 and 1.
• Supplemental oxygen should be titrated to maintain SpO2 between 88-92% to avoid hypercapnia while treating hypoxemia.
• For severe exacerbations, non-invasive ventilation (NIV) should be considered, particularly with respiratory acidosis (pH <7.35) or severe dyspnea, as recommended by 1, 1, and 1.

Rationale

These interventions are based on the most recent and highest quality evidence, including the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1 and the European Respiratory Society/American Thoracic Society guideline on the management of COPD exacerbations 1 and 1. The use of systemic corticosteroids, antibiotics, and NIV has been shown to improve lung function, reduce recovery time, and decrease hospitalization duration, as supported by 1, 1, and 1. By prioritizing these interventions, healthcare providers can minimize morbidity, mortality, and improve quality of life for patients with COPD exacerbations.

From the FDA Drug Label

Adults Acute bacterial exacerbations of chronic obstructive pulmonary disease (mild to moderate) 500 mg QD × 3 days OR 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5

The approach to managing an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) includes the use of azithromycin, with a recommended dose of 500 mg once daily for 3 days or 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 for mild to moderate cases 2.

• Key points:
  • Azithromycin is used to treat acute bacterial exacerbations of COPD.
  • The recommended dose is 500 mg once daily for 3 days or 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5.
  • This treatment is for mild to moderate cases of COPD exacerbation. 2

From the Research

Approach to Managing Acute Exacerbation of COPD

The approach to managing an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) involves several key components, including:

• The use of short-acting inhaled bronchodilators, such as salbutamol (albuterol) and ipratropium bromide, as first-line treatment 3
• The addition of corticosteroids, which have been shown to improve outcomes and reduce the risk of treatment failure 4, 5
• The use of antibiotics, especially in patients with purulent or increased sputum, guided by the local antibiogram of the key microbes 3, 6
• Controlled oxygen therapy, which improves outcome in hypoxaemic patients, with arterial blood gases performed to ensure hypercarbia is not becoming excessive 3, 6
• Consideration of noninvasive positive pressure ventilation in patients who are in distress despite the above measures or if there is acidaemia or hypercarbia 3, 6

Corticosteroid Regimens

The optimal corticosteroid regimen for the management of an acute exacerbation of COPD is still a topic of debate, with different studies suggesting different dosing strategies:

• A short course of corticosteroids (e.g. prednisone 40 mg orally once/day for 10-14 days) may be sufficient for most patients 4, 5
• A short-course corticosteroid taper may be associated with reduced hospital length of stay and decreased corticosteroid exposure without increased risk of treatment failure in critically ill patients 7
• There is no evidence to suggest that parenteral corticosteroids are more effective than oral corticosteroids in reducing treatment failure, relapse, or mortality 5

Other Interventions

Other interventions that may be considered in the management of an acute exacerbation of COPD include:

• Mucous-clearing drugs and chest physiotherapy, which have no proven beneficial role in AECOPD 3, 6
• Noninvasive positive pressure ventilation, which may benefit a group of patients with rapid decline in respiratory function and gas exchange 3, 6