What is the management plan for Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)?

Management of Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)

The management of AECOPD requires prompt bronchodilator therapy, appropriate antibiotics, and selective use of corticosteroids, with treatment setting determined by exacerbation severity. 1

Assessment and Diagnosis

• AECOPD presents as worsening of previous stable situation with increased sputum purulence, increased sputum volume, increased dyspnea, increased wheeze, chest tightness, and/or fluid retention 1
• Consider differential diagnoses including pneumonia, pneumothorax, left ventricular failure, pulmonary embolus, lung cancer, and upper airway obstruction 1
• Determine severity of exacerbation to guide treatment setting (home vs. hospital) 1
• For home management, a confident diagnosis without further acute investigations is sufficient if the patient responds to treatment 1

Treatment Approach

Bronchodilator Therapy

• Add or increase short-acting bronchodilators as first-line treatment 1
• Use beta-agonists (salbutamol 2.5-5 mg or terbutaline 5-10 mg) and/or anticholinergic drugs (ipratropium bromide 0.25-0.5 mg) 1
• For severe exacerbations or poor response to single agent, use both beta-agonists and anticholinergics together 1, 2
• Prefer inhaled route with appropriate device the patient can use effectively 1
• For hospital management, administer nebulized bronchodilators on arrival and at 4-6 hourly intervals thereafter 1
• Consider using compressed air rather than oxygen to drive nebulizers if PaCO2 is raised and/or respiratory acidosis is present 1

Antibiotic Therapy

• Initiate antibiotics if two or more of the following are present: increased breathlessness, increased sputum volume, or development of purulent sputum 1
• Antibiotics can shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration 1
• Duration of antibiotic therapy should be 5-7 days 1
• Azithromycin has shown effectiveness for AECOPD with clinical success rates of 85% compared to 82% for clarithromycin in a 3-day vs. 10-day regimen 3

Corticosteroid Therapy

• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1
• For outpatient management, oral corticosteroids should be used selectively when:
  • The patient is already on oral corticosteroids
  • There is a previously documented response to oral corticosteroids
  • Airflow obstruction fails to respond to increased bronchodilator dose
  • This is the first presentation of airflow obstruction 1
• Recommended dose is prednisolone 30-40 mg per day for 5-7 days 1
• Corticosteroids should not normally be continued long-term after an acute exacerbation 1

Oxygen Therapy

• For hospitalized patients, provide controlled oxygen therapy to maintain oxygen saturation 1
• Target oxygen saturation should achieve PaO2 >7.5 kPa without causing respiratory acidosis 1
• Monitor with pulse oximetry and repeat arterial blood gas measurements as needed 1

Management Based on Setting

Home Management

• Goals: treat bacterial infection, remove excess secretions, increase maximum airflow, and improve respiratory muscle strength 1
• Treatment components:
  • Bronchodilators (increase dose or frequency)
  • Antibiotics (when indicated)
  • Encourage sputum clearance by coughing
  • Consider home physiotherapy
  • Encourage fluid intake
  • Avoid sedatives and hypnotics 1
• Follow up after acute episode, especially if patient fails to respond fully to treatment 1

Hospital Management

• Goals: evaluate severity, identify cause, provide controlled oxygenation, and return patient to best previous condition 1
• Additional treatments may include:
  • Intravenous methylxanthines (aminophylline 0.5 mg/kg/hour) if patient is not responding to first-line treatments, though evidence is limited 1, 4
  • Diuretics if peripheral edema and raised jugular venous pressure are present 1
  • Prophylactic subcutaneous heparin for patients with acute on chronic respiratory failure 1

Ventilatory Support

• Consider non-invasive positive pressure ventilation (NIPPV) or invasive ventilation for patients with pH <7.26 and rising PaCO2 who fail to respond to supportive treatment 1
• NIPPV has been shown to reduce the need for intubation and length of hospital stay 1
• Decision to institute or withhold ventilatory support should be made by a senior clinician with consideration of the patient's premorbid state and wishes 1

Follow-up Care

• Review after an acute exacerbation to assess response to treatment 1
• Use follow-up visit to help patient plan for future and prevent further exacerbations 1
• Provide advice on smoking cessation, lifestyle, activity levels, weight, and review medication 1

Common Pitfalls and Caveats

• Nebulizers are usually not required for home management; ensure appropriate inhaler technique 1
• Ipratropium alone is not adequate for relief of bronchospasm in acute COPD exacerbation 5
• Methylxanthines are not recommended as first-line therapy due to increased side effect profiles 1, 4
• Chest physiotherapy is not recommended in acute exacerbations of COPD 1
• Monitor for side effects of treatments, particularly with theophylline which has a narrow therapeutic index 4
• Consider patient's comorbidities and adjust treatment accordingly 1