What is the management plan for acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

Management of Acute Exacerbation of COPD

The management of acute exacerbation of COPD requires prompt administration of short-acting bronchodilators, systemic corticosteroids, and antibiotics for purulent exacerbations, with oxygen therapy targeting 88-92% saturation to reduce mortality and improve outcomes. 1

Initial Assessment and Diagnosis

• An acute exacerbation is characterized by:

  • Increased dyspnea
  • Increased sputum volume
  • Increased sputum purulence
  • Increased wheeze and chest tightness
  • Fluid retention 1

• Important investigations:

  • Arterial blood gas measurement (noting FiO₂)
  • Chest radiograph
  • Full blood count, urea and electrolytes, ECG
  • Initial FEV₁/peak flow measurement
  • Sputum culture if purulent 2

Pharmacological Management

1. Bronchodilators

• For moderate exacerbations:

  • Short-acting β₂-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) OR
  • Anticholinergic (ipratropium bromide 0.25-0.5 mg) 2

• For severe exacerbations:

  • Combination of both β₂-agonist AND anticholinergic 2, 1
  • Administer via nebulizer initially, then every 4-6 hours (can be more frequent if required) 2

Important: In patients with raised PaCO₂ or respiratory acidosis, nebulizers should be driven by compressed air, not oxygen. Supplemental oxygen can be provided via nasal prongs at 1-2 L/min during nebulization. 2

2. Corticosteroids

• Systemic corticosteroids (oral prednisone 30-40 mg daily for 5-7 days) 2, 1
• Indications:
  • Increased breathlessness
  • Increased sputum volume
  • Development of purulent sputum 1
• Benefits: Reduces treatment failure and relapse within one month 1

3. Antibiotics

• Indications: Presence of at least two of:

  • Increased breathlessness
  • Increased sputum volume
  • Development of purulent sputum 2, 1

• Antibiotic selection:

  • First-line: Amoxicillin or tetracycline
  • Second-line (for more severe exacerbations or poor response): Broad-spectrum cephalosporin or newer macrolide 2, 1
  • Duration: 5-7 days 1

4. Theophylline

• Consider intravenous methylxanthines (aminophylline 0.5 mg/kg per hour) by continuous infusion if patient is not responding to nebulized bronchodilators 2
• Caution: Theophylline is a relatively weak bronchodilator and provides no added benefit in acute bronchospasm compared to inhaled beta-2 agonists 3
• Monitor blood levels daily if administered 2
• Contraindicated in patients with:
  • Active peptic ulcer disease
  • Seizure disorders
  • Cardiac arrhythmias 3

Oxygen Therapy

• Target: PaO₂ of at least 6.6 kPa (or oxygen saturation 88-92%) without causing respiratory acidosis (pH <7.26) 2, 1
• Initial approach:
  • For patients with known COPD aged >50 years: Start with FiO₂ ≤28% via Venturi mask or ≤2 L/min via nasal cannulae 2
  • Check blood gases within 60 minutes of starting oxygen and after any change in concentration 2
  • If PaO₂ improves without pH deterioration, increase oxygen concentration until PaO₂ >7.5 kPa 2

Non-Invasive and Invasive Ventilation

• Consider ventilatory support (NIPPV or IPPV) if:
  • pH <7.26
  • Rising PaCO₂
  • Failure to respond to supportive treatment and controlled oxygen therapy 2, 1
• NIPPV is most effective when initiated early 2
• Poor candidates for NIPPV:
  • Confused patients
  • Large volume of secretions 2

Additional Measures

• Diuretics: Indicated if peripheral edema and raised jugular venous pressure 2
• Anticoagulants: Consider prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure 2
• Physiotherapy: Not routinely recommended in acute COPD exacerbations 2

Severity-Based Management Algorithm

Mild Exacerbation (Outpatient)

1. Short-acting bronchodilators
2. Oral corticosteroids if indicated
3. Antibiotics if purulent sputum
4. Reassess within 48 hours 1

Moderate Exacerbation (May require hospitalization)

1. Oxygen therapy (target 88-92%)
2. Nebulized bronchodilators (β₂-agonist ± anticholinergic)
3. Systemic corticosteroids
4. Antibiotics if indicated
5. Monitor blood gases if hypoxemic or hypercapnic 2, 1

Severe Exacerbation (Requires hospitalization)

1. Controlled oxygen therapy with close monitoring
2. Combination nebulized bronchodilators
3. Systemic corticosteroids
4. Antibiotics
5. Consider NIPPV if pH <7.26 or rising PaCO₂
6. Consider ICU admission if deteriorating despite treatment 2, 1

Follow-up After Acute Episode

• Review medication regimen
• Assess inhaler technique
• Consider preventive strategies:
  • Smoking cessation
  • Vaccination (influenza, pneumococcal)
  • Pulmonary rehabilitation 1

Common Pitfalls to Avoid

1. Administering high-flow oxygen without monitoring blood gases (risk of worsening hypercapnia)
2. Using nebulizers powered by oxygen in hypercapnic patients (use compressed air instead)
3. Continuing oral corticosteroids long-term after an acute episode without clear indication
4. Failing to consider ventilatory support in patients with severe acidosis
5. Overlooking important differential diagnoses (pneumonia, pulmonary embolism, heart failure) 2, 1