What are the guidelines for managing Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AE COPD)?

Management of Acute Exacerbations of COPD (AE-COPD)

Short-acting bronchodilators are the first-line treatment for COPD exacerbations, followed by systemic corticosteroids and antibiotics when indicated, with oxygen therapy carefully titrated to avoid respiratory acidosis. 1

Diagnosis and Assessment

Presentation

An acute exacerbation of COPD typically presents as a worsening of the previous stable condition with:

• Increased sputum purulence
• Increased sputum volume
• Increased dyspnea
• Increased wheeze
• Chest tightness
• Fluid retention 2

Differential Diagnosis

Consider these alternative diagnoses when evaluating a patient with suspected AE-COPD:

• Pneumonia
• Pneumothorax
• Left ventricular failure/pulmonary edema
• Pulmonary embolus
• Lung cancer
• Upper airway obstruction 2

Treatment Algorithm

1. Outpatient Management

For mild exacerbations that can be managed at home:

Bronchodilator Therapy

• Add or increase short-acting bronchodilators (beta-agonists with or without anticholinergics) 2, 1
• Ensure proper inhaler technique and device appropriateness
• For moderate exacerbations: salbutamol 2.5-5 mg or terbutaline 5-10 mg, or ipratropium bromide 0.25-0.5 mg via nebulizer 2
• For severe exacerbations: consider combination of both beta-agonist and anticholinergic 2, 1

Antibiotics

Administer when two or more of the following are present:

• Increased breathlessness
• Increased sputum volume
• Development of purulent sputum 2, 1

First-line antibiotics:

• Amoxicillin or tetracycline (unless recently used with poor response) 2, 1
• Second-line options for more severe cases: broad-spectrum cephalosporin or newer macrolides 2

Corticosteroids

Oral corticosteroids (prednisolone 30-40 mg daily for 5-7 days) should be used when:

• The patient is already on oral corticosteroids
• There is a previously documented response to oral corticosteroids
• The airflow obstruction fails to respond to increased bronchodilator dose
• This is the first presentation of airflow obstruction 2, 1

2. Hospital Management

Oxygen Therapy

• Initial concentration ≤28% via Venturi mask or ≤2 L/min via nasal cannula 2, 1
• Target SpO2 ≥90% or PaO2 ≥60 mmHg 1
• Check blood gases within 60 minutes of starting oxygen and after any change in concentration 2
• If pH falls below 7.26 (due to rising PaCO2), consider alternative ventilatory strategies 2

Bronchodilator Therapy

• Nebulized bronchodilators on arrival and at 4-6 hour intervals 2
• For moderate exacerbations: beta-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) or anticholinergic (ipratropium bromide 0.25-0.5 mg) 2
• For severe exacerbations: combine both agents 2, 1
• If using wall-mounted oxygen to power nebulizers in patients with COPD, switch to compressed air if PaCO2 is raised or respiratory acidosis is present 2

Corticosteroids

• Systemic corticosteroids (prednisolone 30 mg daily or IV hydrocortisone if oral route not possible) for 5-7 days 2, 1
• Do not continue long-term unless specifically indicated 2

Methylxanthines (Theophylline)

• Not recommended as first-line therapy 1
• Consider only if patient is not responding to nebulized bronchodilators 2
• If used, administer via continuous infusion (aminophylline 0.5 mg/kg per hour) 2
• Monitor blood levels daily due to narrow therapeutic index 2, 3
• Reduce dose in elderly, those with liver disease, heart failure, or concurrent illness 3

Additional Measures

• Diuretics if peripheral edema and raised jugular venous pressure are present 2
• Prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure 2

3. Ventilatory Support

Non-invasive Ventilation (NIPPV)

Consider when:

• pH <7.26 with rising PaCO2
• Patient fails to respond to supportive treatment and controlled oxygen therapy 2, 1
• Earlier intervention may reduce need for intubation 2

Invasive Mechanical Ventilation

Consider when:

• NIPPV fails or patient deteriorates rapidly 1
• Factors encouraging use of IPPV include:
  • Demonstrable remedial cause for decline (e.g., pneumonia)
  • First episode of respiratory failure
  • Acceptable quality of life or habitual activity level 2

Hospitalization Criteria

Consider hospital admission when:

• Marked increase in symptom intensity
• Severe underlying COPD
• New physical signs
• Failure to respond to initial treatment within 48 hours
• Significant comorbidities
• Older age
• Insufficient home support 1
• Respiratory distress (tachypnea, use of accessory muscles)
• Oxygen saturation <90%
• Altered mental status 1

Follow-up Care

• Review patients within 48 hours for mild exacerbations managed at home 1
• If patient fails to respond fully to treatment, consider chest radiograph and possible hospital referral 2
• Use follow-up visits to plan prevention of future exacerbations 2
• Provide advice on smoking cessation, lifestyle modifications, activity levels, and weight management 2
• Initiate maintenance therapy with long-acting bronchodilators before hospital discharge 1

Common Pitfalls and Caveats

1. Oxygen therapy: Excessive oxygen can cause respiratory acidosis in COPD patients; always monitor blood gases and adjust accordingly 2

2. Corticosteroids: Prolonged courses (>7 days) increase side effects without additional benefits 1

3. Antibiotics: Avoid indiscriminate use; reserve for patients with signs of bacterial infection, particularly purulent sputum 1

4. Theophylline: Has narrow therapeutic index and significant drug interactions; monitor levels closely if used 3

5. Differential diagnosis: Always consider alternative diagnoses such as pneumonia, pulmonary embolism, or heart failure 2

6. Dosage adjustments: Medication doses should be adjusted for age and renal function, particularly in elderly patients 1