What is the initial management for a patient with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD)?

Initial Management of Acute Exacerbation of COPD (AECOPD)

The initial management of AECOPD should include short-acting bronchodilators (SABA with or without SAMA), systemic corticosteroids, controlled oxygen therapy targeting 88-92% saturation, and antibiotics when indicated by purulent sputum. 1

Assessment and Diagnosis

• Assess for specific symptoms of exacerbation:

  • Increased dyspnea
  • Increased sputum volume
  • Development of purulent sputum

• Obtain key diagnostic tests:

  • Arterial blood gas (with documented FiO₂)
  • Chest radiograph to rule out pneumonia, pneumothorax, and pulmonary edema
  • Consider differential diagnoses (pneumonia, pneumothorax, heart failure, pulmonary embolism)

Pharmacological Management

First-Line Treatments

1. Bronchodilator Therapy

   • Short-acting β₂-agonists (SABA) such as salbutamol/albuterol: 2 puffs every 2-4 hours via MDI with spacer or nebulizer 1
   • Add short-acting muscarinic antagonist (SAMA) such as ipratropium for enhanced bronchodilation 1
   • Note: Ipratropium alone is not adequately studied for acute COPD exacerbations and drugs with faster onset may be preferable as initial therapy 2

2. Systemic Corticosteroids

   • Prednisone/prednisolone 30-40 mg orally daily for 5-10 days 1
   • Oral administration is preferred over intravenous for hospitalized patients
   • Indicated for patients with at least two symptoms (increased dyspnea, sputum volume, or purulent sputum)

3. Oxygen Therapy

   • Target oxygen saturation at 88-92% to avoid excessive oxygen 1
   • Use 24% Venturi mask at 2-3 L/min or nasal cannulae at 1-2 L/min initially
   • Recheck blood gases 30-60 minutes after starting oxygen or changing concentration

4. Antibiotics

   • Indicated when patients present with at least two symptoms, especially with purulent sputum 1
   • First-line options: amoxicillin/ampicillin, doxycycline, or macrolides for 5-14 days

Treatment Based on Exacerbation Severity

Mild Exacerbations

• Outpatient management
• Increase frequency of bronchodilator therapy
• Add oral corticosteroids
• Consider antibiotics if purulent sputum is present
• Follow-up within 48 hours

Moderate to Severe Exacerbations

• Hospitalization or emergency department management
• All first-line treatments as above
• Consider non-invasive ventilation (NIV) for:
  • Respiratory acidosis (pH < 7.35)
  • Persistent hypercapnia (PCO₂ > 45 mm Hg) after 30 minutes of standard medical management

Monitoring and Follow-up

• Monitor carefully for developing hypercapnic respiratory failure
• Initiate maintenance therapy with long-acting bronchodilators before hospital discharge
• Ensure proper inhaler technique
• Schedule follow-up within 1-2 weeks after discharge
• Start pulmonary rehabilitation within 3 weeks after hospital discharge

Important Considerations

• While long-acting bronchodilators (LABA/LAMA) are superior for maintenance therapy 3, they are not the first choice during acute exacerbations
• The FDA warns that combination of ipratropium and beta-agonists has not been shown to be more effective than either drug alone in acute COPD exacerbation 2
• Monitor for immediate hypersensitivity reactions after administration of ipratropium bromide 2
• For patients with frequent exacerbations (≥2 moderate-to-severe exacerbations per year), consider additional preventive strategies after the acute episode resolves 4

Discharge Criteria

• Sustained response to bronchodilators
• Ability to use inhalers correctly
• PEF or FEV1 >70% of predicted or personal best
• Oxygen saturation >90% on room air