What are the diagnosis and treatment options for Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

Diagnosis and treatment of Chronic Obstructive Pulmonary Disease (COPD) exacerbation should prioritize short-acting bronchodilators, systemic corticosteroids, and antibiotics as needed, with consideration for non-invasive ventilation in severe cases, as recommended by the most recent guidelines 1.

Diagnosis of COPD Exacerbation

Diagnosis involves recognizing increased dyspnea, sputum production, and sputum purulence beyond normal day-to-day variations.

Treatment Options

Treatment begins with:

• Short-acting bronchodilators like albuterol (2-4 puffs every 4-6 hours) or ipratropium (2 puffs every 6 hours) to relieve bronchospasm.
• Systemic corticosteroids such as prednisone (40mg daily for 5 days) reduce inflammation and speed recovery, as supported by evidence from 1 and 1.
• For infectious exacerbations, antibiotics are prescribed based on local resistance patterns, with common choices including amoxicillin-clavulanate (875/125mg twice daily for 5-7 days), azithromycin (500mg day 1, then 250mg daily for 4 days), or doxycycline (100mg twice daily for 5-7 days), as recommended by 1 and 1.
• Supplemental oxygen should be provided to maintain oxygen saturation at 88-92%.
• Severe exacerbations may require hospitalization for more intensive treatment including nebulized bronchodilators, intravenous steroids, and potentially non-invasive ventilation, as suggested by 1 and 1.

Follow-Up Care

Following an exacerbation, patients should have follow-up within 2 weeks, medication review, inhaler technique assessment, and smoking cessation counseling if applicable. These interventions target the underlying pathophysiology of COPD exacerbations, which involves increased airway inflammation, mucus hypersecretion, and often bacterial or viral infections that worsen airflow limitation. The most recent and highest quality study 1 supports these recommendations, emphasizing the importance of evidence-based practice in managing COPD exacerbations.

From the FDA Drug Label

The 2 exacerbation trials with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg were identical trials designed to evaluate the effect of fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg and salmeterol 50 mcg, each given twice daily, on exacerbations of COPD over a 12-month period Exacerbations were defined as worsening of 2 or more major symptoms (dyspnea, sputum volume, and sputum purulence) or worsening of any 1 major symptom together with any 1 of the following minor symptoms: sore throat, colds (nasal discharge and/or nasal congestion), fever without other cause, and increased cough or wheeze for at least 2 consecutive days COPD exacerbations were considered of moderate severity if treatment with systemic corticosteroids and/or antibiotics was required and were considered severe if hospitalization was required. In both trials, treatment with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg resulted in a significantly lower annual rate of moderate/severe COPD exacerbations compared with salmeterol

The diagnosis of Chronic Obstructive Pulmonary Disease (COPD) exacerbation is based on worsening of symptoms such as dyspnea, sputum volume, and sputum purulence, or worsening of any 1 major symptom together with any 1 of the minor symptoms. The treatment options for COPD exacerbation include:

• Fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg twice daily, which has been shown to reduce the annual rate of moderate/severe COPD exacerbations compared with salmeterol.
• Systemic corticosteroids and/or antibiotics for moderate severity exacerbations.
• Hospitalization for severe exacerbations. 2

From the Research

Diagnosis of COPD Exacerbation

• COPD exacerbation is a clinical diagnosis based on changes in dyspnea, cough, and/or sputum production in a COPD patient 3
• Spirometry is the reference standard for diagnosing and assessing the severity of COPD 4
• Diagnosis can be complicated by comorbid conditions and undiagnosed COPD in patients presenting with an acute exacerbation 3

Treatment Options for COPD Exacerbation

• Pharmacologic strategies:
  • Inhaled bronchodilators 5, 3
  • Systemic steroids 5, 3, 6
  • Antibiotics 5, 3
• Non-pharmacologic strategies:
  • Oxygen therapy 4, 5
  • Non-invasive ventilation with capnography 3
  • Pulmonary rehabilitation 4, 5
  • Smoking cessation 4, 5
  • Immunization with pneumococcal vaccine 5
• Advanced treatments:
  • Long-term oxygen therapy (LTOT) 5
  • Ambulatory oxygen therapy 5
  • Short-burst oxygen therapy 5
  • Extracorporeal membrane oxygenation (ECMO) 5
  • Lung volume reduction surgery (LVRS) 5
  • Endobronchial procedures 5
  • Lung transplant 5

Goals of COPD Treatment

• Focus on symptoms and exacerbations 7
• Recognize the impact of symptoms and exacerbations on patients' lives 7
• Include both pharmacologic and non-pharmacologic approaches 7
• Monitor treatment outcomes and adjust management strategies accordingly 7