What is the treatment for a patient with a COPD (Chronic Obstructive Pulmonary Disease) infective exacerbation?

Management of COPD Infective Exacerbation

The treatment of COPD infective exacerbation should include short-acting bronchodilators, a 5-day course of systemic corticosteroids, and antibiotics when there is increased sputum purulence, along with controlled oxygen therapy if needed. 1

Diagnosis and Assessment

An acute exacerbation of COPD is characterized by:

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence (Anthonisen criteria)
• Increased wheeze
• Chest tightness
• Fluid retention 1, 2

Important differential diagnoses to consider:

• Pneumonia
• Pneumothorax
• Left ventricular failure/pulmonary edema
• Pulmonary embolus
• Lung cancer
• Upper airway obstruction 2, 1

Treatment Algorithm

1. Bronchodilator Therapy

• First-line: Short-acting β2-agonists (e.g., salbutamol 2.5-5 mg) with or without short-acting anticholinergics (e.g., ipratropium bromide 0.25-0.5 mg) 1
• Administer via nebulizer or inhaler with spacer
• Increase dose or frequency if previously on these medications 2
• Consider if inhaler device and technique are appropriate 2

2. Corticosteroid Therapy

• Oral prednisone 40 mg daily for 5 days 1, 3
• A 5-day course is as effective as longer courses (14 days) with significantly reduced glucocorticoid exposure 3
• High-quality evidence supports the use of systemic corticosteroids to reduce the likelihood of treatment failure and relapse within one month 4
• Indications for corticosteroids:
  • Patient already on oral corticosteroids
  • Previously documented response to oral corticosteroids
  • Airflow obstruction fails to respond to increased bronchodilator dose 2

3. Antibiotic Therapy

• Indicated when patient has at least two of:
  • Increased breathlessness
  • Increased sputum volume
  • Development of purulent sputum 2, 1
• Selection of antibiotics:
  • Mild cases: Amoxicillin or tetracycline
  • Moderate to severe cases: Amoxicillin-clavulanate
  • Risk of Pseudomonas: Ciprofloxacin 1
• Duration: 5-7 days 1

4. Oxygen Therapy (if hospitalized)

• Target oxygen saturation: 88-92% 1
• Start with low-flow controlled oxygen in hypoxemic patients
• Monitor arterial gases within 60 minutes if initially acidotic or hypercapnic 1

Treatment Setting Decision

Outpatient Management (Mild Exacerbation)

• Mild increase in symptoms
• No significant respiratory distress
• No signs of respiratory failure
• Adequate home support 1

Hospital Evaluation (Moderate to Severe Exacerbation)

• Marked increase in dyspnea
• Respiratory rate >30/min
• Use of accessory respiratory muscles
• New onset cyanosis or peripheral edema
• Impaired consciousness
• Failure to respond to initial treatment 1

Follow-up

• Mild exacerbations: Reassess within 48 hours 1
• Moderate exacerbations: Follow-up within 1-2 weeks after discharge 1
• Monitor for:
  • Worsening symptoms
  • Decreasing oxygen saturation
  • Altered mental status
  • Inability to maintain oral intake 1
• Review medication, smoking status, and lifestyle advice 2

Special Considerations

• Renal insufficiency: Avoid medications with significant renal elimination and adjust dosages 1
• Diabetes: Monitor blood glucose levels more frequently when taking corticosteroids 1
• Beta-blockers: Patients may have reduced response to beta-agonists 1
• Severe respiratory failure: Consider non-invasive ventilation as first option if no contraindications 1

Prevention of Future Exacerbations

• Smoking cessation
• Vaccination (influenza, pneumococcal)
• Appropriate maintenance therapy
• Pulmonary rehabilitation
• Early recognition and treatment of exacerbations 1

The most recent high-quality evidence strongly supports a shorter 5-day course of systemic corticosteroids, which is as effective as longer courses while significantly reducing steroid exposure and potential adverse effects 3, 5.