What is the treatment protocol for acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

Treatment Protocol for Acute Exacerbation of COPD

For acute exacerbation of COPD, the treatment protocol should include bronchodilators (short-acting beta-agonists and anticholinergics), systemic corticosteroids (prednisone 30-40mg daily for 5 days), controlled oxygen therapy targeting 88-92% saturation, and consideration of antibiotics for purulent sputum, with non-invasive ventilation for patients with respiratory acidosis. 1

Initial Assessment and Categorization

• Assess exacerbation severity to guide treatment approach:

  • Mild: Outpatient treatment
  • Moderate: May require emergency room visit or hospitalization
  • Severe: Requires hospitalization with intensive management 1

• Diagnostic evaluation should include:

  • Arterial blood gas measurement to assess respiratory failure
  • Chest radiograph to identify complications or alternative diagnoses
  • Basic laboratory tests (CBC, electrolytes, ECG)
  • Sputum culture if purulent sputum is present 1

Pharmacological Management

Bronchodilator Therapy

1. Short-acting bronchodilators:

   • Salbutamol 200-400 μg via hand-held inhaler, repeated as needed based on clinical response
   • Alternatively, nebulized salbutamol 2.5-5 mg every 4-6 hours for 24-48 hours 1

2. Combination therapy:

   • Add ipratropium bromide (250-500 μg) for more severe exacerbations
   • Combination therapy produces additive effects at submaximal doses 1

Corticosteroid Therapy

• Systemic corticosteroids are the primary treatment for COPD exacerbations
• Prednisone 30-40mg daily for 5 days is the recommended regimen
• Reduces risk of treatment failure and relapse 1

Antibiotic Therapy

• Indicated when purulent sputum is present
• Consider local antibiotic resistance patterns when selecting antibiotics 1

Oxygen Therapy and Ventilatory Support

Controlled Oxygen Therapy

• Target oxygen saturation of 88-92% to prevent worsening respiratory acidosis
• Use Venturi mask with initial FiO₂ of no more than 28% until arterial blood gases are known
• Check arterial blood gases within 60 minutes of starting oxygen and after any change in FiO₂ 1

Non-Invasive Ventilation (NIV)

• Initiate NIV if pH <7.35 and pCO₂ >6.5 kPa persist despite optimal medical therapy
• Do not delay NIV in extreme acidosis (pH <7.25)
• Monitor response through arterial blood gases and clinical parameters 1

Management Based on Exacerbation Severity

Mild Exacerbations

• Increase frequency of bronchodilator therapy
• Add oral corticosteroids (prednisone 30-40 mg daily for 5 days)
• Consider antibiotics if purulent sputum is present
• Follow-up within 48 hours to assess response 1

Moderate to Severe Exacerbations

• Assess for life-threatening conditions
• Identify the cause of exacerbation
• Provide controlled oxygen therapy
• Aim to return the patient to their best previous condition 1

Discharge Planning and Prevention

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 1

Follow-up and Maintenance Therapy

• Initiate maintenance therapy with long-acting bronchodilators before discharge
• Schedule follow-up within 1-2 weeks after discharge
• Start pulmonary rehabilitation within 3 weeks after hospital discharge 1

Prevention Strategies

• Smoking cessation
• Vaccination (influenza, pneumococcal)
• Appropriate maintenance therapy
• Consider prophylactic macrolide therapy for patients with frequent exacerbations 1

Special Considerations and Pitfalls

• Proper inhaler technique is crucial for optimal drug delivery - ensure patients can demonstrate correct technique before discharge 1

• Monitor for side effects of beta-agonists such as tachycardia and potential decrease in PaO2 1

• Consider differential diagnoses such as pneumonia, pneumothorax, heart failure, pulmonary embolism, and upper airway obstruction 1

• Avoid excessive oxygen which can worsen hypercapnia in COPD patients 1

• Do not delay NIV in patients with severe respiratory acidosis as this can lead to need for invasive mechanical ventilation 1

• Recognize that Wixela Inhub (salmeterol/fluticasone) is indicated for maintenance treatment of COPD and reducing exacerbations, but is NOT indicated for relief of acute bronchospasm during an exacerbation 2

The evidence strongly supports a systematic approach to COPD exacerbation management with bronchodilators, corticosteroids, and appropriate respiratory support as the cornerstones of therapy, with careful attention to oxygen administration and consideration of non-invasive ventilation for respiratory failure.