How to manage a patient with suspected acute exacerbation of chronic airway disease?

Management of Suspected Acute Exacerbation of Chronic Airway Disease

For patients with suspected acute exacerbation of chronic airway disease, treatment should include increased bronchodilator therapy, systemic corticosteroids (prednisone 30-40mg daily for 5 days), and antibiotics if purulent sputum is present, along with controlled oxygen therapy targeting 88-92% saturation if hypoxemic. 1

Initial Assessment and Diagnosis

• Evaluate for key symptoms of exacerbation:

  • Increased dyspnea
  • Increased sputum volume
  • Increased sputum purulence
  • Increased wheeze
  • Chest tightness
  • Fluid retention 2

• Rule out important differential diagnoses:

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

• Diagnostic evaluation:

  • Arterial blood gas measurement (if moderate-severe exacerbation)
  • Chest radiograph
  • Basic laboratory tests (CBC, electrolytes, ECG)
  • Sputum culture if purulent sputum is present 1

Pharmacological Management

Bronchodilators

• Add or increase bronchodilators:
  • Short-acting β2-agonists (salbutamol 200-400 μg via MDI or 2.5-5 mg nebulized every 4-6 hours) 1
  • Consider combination therapy with ipratropium bromide (250-500 μg) for more severe exacerbations 1
  • Ensure proper inhaler technique or nebulizer setup 1

Corticosteroids

• Systemic corticosteroids are recommended as primary treatment:
  • Prednisone 30-40mg daily for 5 days 1
  • Short-course therapy (5 days) is as effective as longer courses (14 days) with significantly reduced glucocorticoid exposure 3
  • Oral route is preferred unless patient cannot tolerate oral medications 1

Antibiotics

• Indicated if two or more of the following are present:

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

• Consider macrolide therapy (e.g., azithromycin) for patients with moderate to severe COPD who have ≥1 exacerbation in the previous year despite optimal inhaler therapy 1

  • Azithromycin has shown clinical success rates of 85% in acute exacerbations of chronic bronchitis 4

Oxygen Therapy and Ventilatory Support

• Provide controlled oxygen therapy with target saturation of 88-92% 1

• Use Venturi mask with initial FiO₂ of no more than 28% until arterial blood gases are known 1

• Check arterial blood gases within 60 minutes of starting oxygen and after any change in FiO₂ 1

• Consider non-invasive ventilation (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) 1

Management Based on Exacerbation Severity

Mild Exacerbations (Outpatient Management)

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

Moderate to Severe Exacerbations (Hospital Management)

• All of the above plus:
• Controlled oxygen therapy
• Consider NIV if respiratory acidosis develops
• Monitor for worsening respiratory failure 1

Discharge and Follow-up

• Ensure patient has adequate support at home
• Verify patient understands treatment and proper use of delivery devices
• Provide sufficient medication until next follow-up
• Schedule follow-up within 1-2 weeks after discharge
• Consider starting pulmonary rehabilitation within 3 weeks after hospital discharge 1

Prevention of Future Exacerbations

• Maintenance therapy with long-acting bronchodilators
• Consider triple therapy (LAMA/ICS/LABA) for patients with frequent exacerbations
• Consider PDE-4 inhibitors (roflumilast) for patients with chronic bronchitis and history of exacerbations
• Ensure proper vaccination (influenza, pneumococcal)
• Smoking cessation counseling 1

Important Clinical Considerations

• Short-course systemic corticosteroids (5 days) are as effective as longer courses (14 days) with fewer side effects 5, 3
• Inhaled corticosteroids alone are not recommended for acute exacerbations, though they may be used in combination with systemic therapy 6, 7
• Early outpatient treatment with prednisone accelerates recovery of lung function and reduces treatment failure rates 8
• Monitor for side effects of bronchodilators such as tachycardia and potential decrease in PaO2 1