How to relieve the symptoms of an acute COPD exacerbation?

Management of Acute COPD Exacerbations

Short-acting bronchodilators, systemic corticosteroids, and antibiotics (when appropriate) are the cornerstones of treatment for acute COPD exacerbations to reduce symptoms, prevent clinical failure, and improve outcomes. 1, 2

First-Line Pharmacologic Therapy

Bronchodilators

• Short-acting bronchodilators are routinely recommended as first-line therapy to improve symptoms in acute COPD exacerbations 1
  • Short-acting β2-agonists (SABA) like albuterol (indicated for relief of bronchospasm) 3
  • Short-acting muscarinic antagonists (SAMA) like ipratropium 4
  • Either agent can be used as first-line therapy; choice depends on potential side effects and patient's comorbidities 5
  • Administration via metered-dose inhaler with spacer is as effective as nebulized treatment 5
  • For severe exacerbations, consider combination therapy (SABA + SAMA) 1, 2

Corticosteroids

• Systemic corticosteroids are recommended for all patients with acute COPD exacerbations to reduce clinical failure (weak recommendation, low quality evidence) 1, 2
• A short course (e.g., 40 mg oral prednisone daily for 5 days) is as effective as longer courses 2
• Patients with sputum eosinophilia are more likely to respond favorably 2
• Long-term systemic corticosteroid use is not recommended due to significant adverse effects 2

Antibiotics

• Consider antibiotics when there is:
  • Increased sputum purulence
  • Increased sputum volume
  • Worsening dyspnea 5
• Recommended duration is 5-7 days 2
• Particularly beneficial for patients with severe exacerbations 5

Oxygen Therapy

• Titrate oxygen to maintain SpO2 ≥90% or PaO2 ≥60 mmHg 2
• In patients with COPD history aged 50+ years, avoid giving oxygen at FiO2 >28% via Venturi mask or >2 L/min via nasal cannulae until arterial blood gases are known 2
• Check blood gases within 60 minutes of starting oxygen therapy 2

Additional Considerations

Theophylline/Aminophylline

• Not recommended as first-line treatment due to limited efficacy and risk of toxicity 2
• May be considered only for patients with life-threatening features who fail to respond to standard treatments 2

Non-invasive Positive Pressure Ventilation (NIPPV)

• Consider for patients with rapid decline in respiratory function and gas exchange 5
• May decrease need for intubation and invasive mechanical ventilation 5

Follow-up and Monitoring

• Schedule follow-up within 3-6 months with repeat spirometry 2
• Monitor for decline in FEV1 >50 mL/year, which may indicate need for more aggressive therapy 2

Prevention of Future Exacerbations

• For patients with moderate to severe COPD and history of exacerbations, consider:
  • Long-acting muscarinic antagonist (LAMA) compared with placebo (Grade 1A) 1
  • Maintenance combination inhaled corticosteroid/long-acting β-agonist therapy compared with placebo (Grade 1B) 1
  • LAMA/LABA combination therapy for patients with frequent exacerbations 6

Common Pitfalls to Avoid

• Delaying corticosteroid administration
• Overuse of antibiotics when not indicated (no purulent sputum)
• Prolonged courses of systemic corticosteroids (increased risk of adverse effects)
• Inadequate oxygen monitoring (risk of hypercapnia in CO2 retainers)
• Relying on theophylline as first-line therapy
• Failing to address maintenance therapy for prevention of future exacerbations

By following this evidence-based approach to managing acute COPD exacerbations, clinicians can effectively relieve symptoms, reduce the risk of clinical failure, and improve patient outcomes.