What are the diagnosis and management strategies for asthma and Chronic Obstructive Pulmonary Disease (COPD) exacerbations according to the Global Initiative for Asthma (GINA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2025 guidelines?

Diagnosis and Management of Asthma and COPD Exacerbations According to GINA and GOLD 2025 Guidelines

For both asthma and COPD exacerbations, prompt diagnosis and appropriate treatment with short-acting bronchodilators, systemic corticosteroids, and antibiotics (when indicated) are essential to reduce morbidity and mortality and improve quality of life outcomes. 1

Diagnosis of Exacerbations

Asthma Exacerbation Diagnosis

• Defined as acute or subacute worsening of symptoms and lung function compared with the patient's normal status requiring a change in treatment 2
• Key symptoms: Progressive increase in shortness of breath, cough, wheeze, or chest tightness not responding to usual bronchodilator therapy 2
• Assessment tools:
  • Clinical evaluation of symptoms severity
  • Peak expiratory flow (PEF) measurements
  • Oxygen saturation monitoring
  • Arterial blood gas analysis (in severe cases)

COPD Exacerbation Diagnosis

• Defined as an acute worsening of respiratory symptoms resulting in additional therapy 2
• Classification:
  • Mild: Treated with short-acting bronchodilators only
  • Moderate: Treated with short-acting bronchodilators plus antibiotics and/or oral corticosteroids
  • Severe: Requires hospitalization or emergency room visit; may be associated with acute respiratory failure 2
• Key symptoms: Increased dyspnea, increased sputum volume, and increased sputum purulence 2
• Differential diagnosis: Must be differentiated from acute coronary syndrome, worsening heart failure, pulmonary embolism, and pneumonia 2

Management of Asthma Exacerbations

Pharmacological Treatment

1. Bronchodilators:

   • Short-acting β2-agonists (SABA) like albuterol/salbutamol as first-line therapy
   • Consider adding ipratropium bromide for moderate to severe exacerbations 2

2. Corticosteroids:

   • Oral corticosteroids for mild to severe exacerbations
   • IV corticosteroids for severe exacerbations 2
   • Recent evidence supports fixed-dose combination of albuterol-budesonide as rescue medication to reduce risk of severe asthma exacerbations by 26% compared to albuterol alone 3

3. Oxygen Therapy:

   • Target oxygen saturation 92-95% 2

4. Novel Approaches:

   • Anti-inflammatory reliever (AIR) therapy with budesonide-formoterol or budesonide-albuterol combinations show promise in reducing exacerbations 4

Severity-Based Management

• Mild: SABA, consider oral corticosteroids
• Moderate: SABA + ipratropium, oral corticosteroids
• Severe: SABA + ipratropium, IV corticosteroids, oxygen therapy, consider hospitalization

Management of COPD Exacerbations

Pharmacological Treatment

1. Bronchodilators:

   • Short-acting inhaled β2-agonists with or without short-acting anticholinergics are recommended as initial bronchodilators 2, 1
   • No significant differences in FEV1 when using metered dose inhalers or nebulizers, though nebulizers may be easier for sicker patients 2

2. Corticosteroids:

   • Systemic glucocorticoids improve lung function, oxygenation, and shorten recovery time
   • Recommended dose: 40 mg prednisone daily for 5 days 2
   • Oral prednisolone is equally effective as intravenous administration 2
   • May be less effective in patients with lower blood eosinophil levels 2

3. Antibiotics:

   • Indicated when patient has:
     • All three cardinal symptoms (increased dyspnea, sputum volume, and purulence)
     • Two cardinal symptoms including purulent sputum
     • Requires mechanical ventilation 1
   • Recommended antibiotics:
     • Mild exacerbations: Amoxicillin or tetracycline
     • Moderate-severe exacerbations: Amoxicillin-clavulanate
     • When P. aeruginosa risk factors present: Ciprofloxacin or β-lactam with anti-pseudomonal activity 1
   • Duration: 5-7 days 2, 1

4. Oxygen Therapy:

   • Target SpO2 ≥90% or PaO2 ≥60 mmHg 1
   • Monitor arterial blood gases within 60 minutes of starting oxygen therapy 1

Severity-Based Management

• Mild: Outpatient management with increased short-acting bronchodilators
• Moderate: Short-acting bronchodilators, systemic corticosteroids, consider antibiotics
• Severe: Hospitalization, bronchodilators, systemic corticosteroids, antibiotics, oxygen therapy, consider non-invasive ventilation 2, 1

Non-Invasive Ventilation (NIV)

• Should be first mode of ventilation for COPD patients with acute respiratory failure without absolute contraindications 2
• Improves gas exchange, reduces work of breathing and need for intubation
• Decreases hospitalization duration and improves survival 2

Follow-up and Prevention

COPD

• Mild exacerbations: Review within 48 hours
• Moderate exacerbations: Follow-up within 1-2 weeks of discharge 1
• Discharge care should include:
  • Education on proper inhaler technique
  • Medication optimization
  • Initiation of maintenance therapy with long-acting bronchodilators 1

Asthma

• Review within 1-2 weeks after exacerbation
• Adjust maintenance therapy as needed
• Consider fixed-dose combination of ICS-LABA for maintenance therapy
• Consider albuterol-budesonide as rescue medication to reduce future exacerbation risk 3, 5

Special Considerations

Asthma-COPD Overlap Syndrome (ACOS)

• Characterized by features of both asthma and COPD
• Criteria: Age >40 years, smoking history, previous asthma diagnosis, persistent airflow limitation with reversible airway obstruction 6
• Treatment: Combination of optimal COPD and asthma treatments 6

Comorbidities

• Renal impairment: Avoid medications with significant renal clearance
• Diabetes: Monitor blood glucose levels more frequently when on corticosteroids 1
• Beta-blockers: May reduce response to beta-agonists 1

Common Pitfalls to Avoid

1. Overreliance on SABA alone for asthma exacerbations without addressing underlying inflammation
2. Inappropriate use of methylxanthines (not recommended due to side effects) 2
3. Delayed initiation of antibiotics in COPD exacerbations with purulent sputum
4. Failure to consider comorbidities that may mimic or exacerbate respiratory symptoms
5. Inadequate follow-up after exacerbation to prevent recurrence

By following these evidence-based guidelines for diagnosis and management of asthma and COPD exacerbations, clinicians can significantly reduce morbidity, mortality, and improve quality of life for patients with these common respiratory conditions.