Management of Acute Exacerbations of COPD (2025)
For patients experiencing acute exacerbations of COPD, treatment should include short-acting bronchodilators, systemic corticosteroids, and antibiotics when indicated, with hospitalization for severe cases requiring respiratory support. 1, 2
Definition and Assessment
Acute exacerbation of COPD (AE-COPD) is characterized by:
- Worsening of respiratory symptoms beyond normal day-to-day variations
- Increased dyspnea, sputum volume, and/or sputum purulence
- Need for additional therapy
Severity Classification:
- Mild: Managed with short-acting bronchodilators only
- Moderate: Requires systemic corticosteroids and/or antibiotics
- Severe: Requires hospitalization or emergency department visit
Pharmacological Management
1. Bronchodilator Therapy
- First-line treatment: Short-acting bronchodilators
- Short-acting beta-agonists (SABAs) like albuterol
- Short-acting muscarinic antagonists (SAMAs) like ipratropium
- Consider combination therapy for severe exacerbations 2
Caution: Ipratropium as a single agent for acute exacerbations has not been adequately studied; drugs with faster onset may be preferable as initial therapy 3
2. Systemic Corticosteroids
- Recommended: Oral prednisone 30-40 mg daily for 5 days 2
- Benefits include:
- Reduced risk of treatment failure
- Improved lung function
- Prevention of hospitalization for subsequent exacerbations within 30 days 1
- Oral administration is as effective as intravenous for most patients
3. Antibiotics
- Indicated when: Patient has increased dyspnea, increased sputum volume, AND purulent sputum 2
- Recommended regimen: Doxycycline 200 mg on day 1, followed by 100 mg daily for 5-7 days 2
- Alternative options include amoxicillin/clavulanate, macrolides, or respiratory fluoroquinolones based on local resistance patterns
Oxygen Therapy
- Start with low-flow oxygen (≤28% via Venturi mask or ≤2 L/min via nasal cannula)
- Target SpO2 ≥90% or PaO2 ≥60 mmHg 2
- Check arterial blood gases within 60 minutes of starting oxygen
- Monitor for CO2 retention (avoid pH drop below 7.26)
Hospitalization Criteria
Consider hospitalization when:
- Marked increase in symptom intensity
- Failure to respond to initial treatment within 48 hours
- Respiratory distress
- Oxygen saturation <90%
- Altered mental status
- Insufficient home support 2
Discharge and Follow-up
Discharge Care Bundle:
- Education on proper inhaler technique
- Medication optimization
- Initiation of maintenance therapy with long-acting bronchodilators 2
Follow-up:
- Review patients within 48 hours for mild exacerbations managed at home
- Assess response to treatment and adjust management plan as needed 2
Prevention of Future Exacerbations:
- Consider maintenance therapy with:
- Consider long-term macrolide therapy for patients with moderate to severe COPD who have a history of one or more exacerbations in the previous year despite optimal maintenance inhaler therapy 1
Special Considerations
- Telemedicine: May provide additional assistance in management, with evidence showing lower rates of hospital admissions and readmissions when integrated with discharge bundles 1
- Standardized Order Sets: Implementation of guideline recommendations in order sets has been shown to reduce length of hospital stay, readmissions, and prescribing errors 1
- Pulmonary Rehabilitation: Should be implemented following hospitalization for COPD exacerbation 2
Common Pitfalls to Avoid
- Overuse of antibiotics in patients without signs of bacterial infection
- Prolonged courses of systemic corticosteroids beyond 5-7 days
- Inadequate oxygen therapy leading to hypoxemia or excessive oxygen leading to CO2 retention
- Failure to address comorbidities that may contribute to or complicate COPD exacerbations
- Discharge without proper follow-up plan or maintenance therapy optimization
The management of AE-COPD requires prompt intervention with appropriate pharmacological therapy and consideration of hospitalization for severe cases to reduce morbidity and mortality associated with these events.