What is the recommended treatment for a patient experiencing a Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

Treatment of COPD Exacerbations

For patients experiencing a COPD exacerbation, the recommended treatment includes short-acting bronchodilators, systemic corticosteroids (30-40 mg prednisone for 5-7 days), and antibiotics when indicated, with treatment setting determined by exacerbation severity. 1, 2

Initial Assessment and Treatment Setting Decision

• Evaluate severity of underlying COPD, presence of comorbidities, and history of previous exacerbations to determine appropriate treatment setting 1
• Consider hospitalization for patients with marked increase in dyspnea, worsening hypoxemia/hypercapnia, changes in mental status, inadequate response to outpatient management, or inability to care for themselves 1
• Indications for ICU admission include impending/actual respiratory failure, other end-organ dysfunction, or hemodynamic instability 1

Pharmacological Treatment

Bronchodilator Therapy (First-Line)

• Increase dose or frequency of short-acting bronchodilators as the initial treatment for all COPD exacerbations 1, 2
• Use short-acting β2-agonists (salbutamol 2.5-5 mg) with or without short-acting anticholinergics (ipratropium 0.25-0.5 mg) via MDI with spacer or nebulizer 1, 2
• For hospitalized patients requiring intensive care, administer short-acting β2-agonist and ipratropium via MDI with spacer, two puffs every 2-4 hours 1
• Consider adding a long-acting bronchodilator if patient is not already using one 1, 3

Corticosteroid Therapy

• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1, 2
• Recommended dosage: prednisone 30-40 mg orally daily for 5-7 days (shorter course of 5 days is as effective as longer courses) 1, 2
• For patients unable to take oral medications, administer equivalent intravenous dose 1
• Oral route is as effective as intravenous administration for hospitalized patients 1

Antibiotic Therapy

• Initiate antibiotics when patients have increased sputum purulence plus increased dyspnea and/or increased sputum volume 1, 2
• Antibiotics reduce the risk of short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1
• Duration of antibiotic therapy should be 5-7 days 1, 2
• First-line options based on local resistance patterns: amoxicillin/ampicillin, cephalosporins, doxycycline, or macrolides 1
• For patients who have failed prior antibiotic therapy, consider amoxicillin/clavulanate or respiratory fluoroquinolones 1
• For patients requiring intensive care with suspected Pseudomonas or Enterobacteriaceae, select appropriate coverage based on local resistance patterns 1

Oxygen Therapy (For Hospitalized Patients)

• Monitor arterial blood gases for PaO2, PaCO2, and pH in severe exacerbations 1
• Maintain PaO2 ≥8 kPa (60 mmHg) or SpO2 ≥90% to prevent tissue hypoxia 1, 2
• Avoid excessive oxygenation as it may increase risk of CO2 retention and respiratory acidosis 1

Treatment Based on Setting

Outpatient Management

• Patient education and check of inhalation technique 1
• Consider use of spacer devices 1
• Short-acting bronchodilators as needed 1, 4
• Prednisone 30-40 mg daily for 5-7 days 1, 2
• Antibiotics if indicated by sputum changes 1

Hospital Management

• Supplemental oxygen therapy with appropriate monitoring 1
• Regular short-acting bronchodilators via appropriate delivery device 1, 4
• Systemic corticosteroids 1
• Antibiotics when indicated 1
• Consider noninvasive ventilation (NIV) for patients with acute or acute-on-chronic respiratory failure, as it improves gas exchange, reduces work of breathing, decreases need for intubation, and improves survival 1, 2

Common Pitfalls and Considerations

• Methylxanthines (e.g., aminophylline) are not recommended as first-line therapy due to increased side effect profiles 1, 2
• Blood eosinophil levels may predict response to corticosteroid therapy - patients with lower levels may have less benefit 1
• Consider comorbidities when selecting treatments, especially cardiac conditions that may be affected by bronchodilators 2
• For patients with frequent exacerbations, consider maintenance therapy with LAMA/LABA combinations after resolution of the acute episode 3, 5
• Ensure proper inhaler technique, as poor technique can significantly reduce medication effectiveness 2