Management of Acute COPD Exacerbation in a 76-Year-Old Male
For this 76-year-old male with an acute COPD exacerbation presenting with green sputum and a history of multiple exacerbations, azithromycin 500 mg orally x 1 dose followed by 250 mg orally once daily x 4 days and prednisone 40 mg orally once daily x 5 days should be initiated in addition to short-acting bronchodilators.
Rationale for Systemic Corticosteroids
Systemic corticosteroids are a cornerstone of COPD exacerbation management:
- High-quality evidence supports the use of systemic corticosteroids to reduce treatment failure and improve lung function during COPD exacerbations 1
- Oral prednisone 40 mg daily for 5 days is an appropriate regimen that provides clinical benefit while minimizing steroid exposure 2
- Short-course (5-day) corticosteroid therapy has been shown to be noninferior to longer courses (14 days) with significantly reduced glucocorticoid exposure 2
- Oral administration is preferred over intravenous administration as there is no evidence of benefit for parenteral treatment compared with oral treatment 1
Rationale for Antibiotic Therapy
The addition of an antibiotic is warranted in this case:
- The patient presents with increased dyspnea, increased sputum volume, and purulent (green) sputum, which are indicators for antibiotic therapy in COPD exacerbations 3
- Azithromycin is FDA-approved for acute bacterial exacerbations of COPD due to common respiratory pathogens 4
- The recommended dosing for azithromycin in this setting is 500 mg on day 1, followed by 250 mg once daily for 4 additional days 4
Key Considerations for This Patient
Severity Assessment
- This patient has had two exacerbations in the past year with one requiring hospitalization
- Current hospitalization indicates moderate-to-severe exacerbation
- Green sputum suggests bacterial infection
Comorbidities
- Heart failure with preserved ejection fraction requires careful fluid management
- Depression may affect adherence and recovery
- Hypertension should be monitored during corticosteroid therapy
Monitoring and Additional Management
- Monitor oxygen saturation continuously and assess work of breathing
- Check arterial blood gases within 60 minutes of starting oxygen therapy
- Target SpO2 ≥90% or PaO2 ≥60 mmHg with low-flow oxygen
- Monitor for hyperglycemia, which occurs more frequently with corticosteroid treatment 1
- Assess response to treatment daily and adjust management as needed
Potential Pitfalls and Caveats
- Avoid high-dose intravenous methylprednisolone as it increases adverse effects without providing additional clinical benefit 5
- Be cautious with beta-agonists as the patient is on metoprolol, which may reduce response to beta-agonists 3
- Monitor for fluid retention due to corticosteroids, especially important in a patient with heart failure
- Assess for QT prolongation risk when administering azithromycin, particularly with other medications the patient may be taking
Discharge Planning
- Implement a discharge care bundle including education and inhaler technique assessment
- Consider pulmonary rehabilitation after resolution of the acute exacerbation
- Evaluate the need for triple therapy (LAMA/LABA/ICS) given the patient's history of frequent exacerbations
The combination of oral prednisone and azithromycin provides the most appropriate balance of efficacy and safety for this patient with an acute COPD exacerbation, based on the highest quality evidence available.