What is the recommended management for infectious exacerbations of Chronic Obstructive Pulmonary Disease (COPD)?

Management of Infectious Exacerbations of COPD

For infectious exacerbations of COPD, the recommended management includes short-acting bronchodilators, systemic corticosteroids for 5-7 days, and antibiotics when indicated by increased sputum purulence, volume, and increased dyspnoea. 1

Classification of Exacerbations

COPD exacerbations are classified as:

• Mild: Treated with short-acting bronchodilators only 1
• Moderate: Treated with short-acting bronchodilators plus antibiotics and/or oral corticosteroids 1
• Severe: Patient requires hospitalization or emergency room visit; may be associated with acute respiratory failure 1

Initial Assessment

• Evaluate severity of exacerbation based on:
  • Increased dyspnea (key symptom) 1
  • Increased sputum purulence and volume 1
  • Increased cough and wheeze 1
• Differentiate from other conditions (acute coronary syndrome, heart failure, pulmonary embolism, pneumonia) 1
• Determine appropriate treatment setting (outpatient vs. hospital) based on severity 1

Pharmacological Treatment

Bronchodilators

• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, are the initial bronchodilators recommended 1
• Can be delivered via metered dose inhalers with spacers or nebulizers (no significant difference in effectiveness, though nebulizers may be easier for sicker patients) 1
• Intravenous methylxanthines are not recommended due to side effects 1

Corticosteroids

• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time 1
• Recommended dose: 40 mg prednisone daily for 5 days 1
• Duration should not exceed 5-7 days 1
• Oral prednisolone is equally effective as intravenous administration 1
• May be less effective in patients with lower blood eosinophil levels 1

Antibiotics

• Indicated when there is increased sputum purulence PLUS either increased sputum volume or increased dyspnea 1
• Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses 1
• First-line options:
  • Amoxicillin 1
  • Doxycycline 1
  • Amoxicillin/clavulanic acid 1
• Alternative options (for treatment failures or specific pathogens):
  • Newer cephalosporins 1
  • Macrolides 1
  • Fluoroquinolones 1
• Duration: 5-7 days for most infections 1

Management Based on Setting

Home Management

• Goals:
  • Treat bacterial infection if present 1
  • Remove excess secretions 1
  • Increase maximum airflow 1
  • Improve respiratory muscle strength 1
• Treatment components:
  • Antibiotics when indicated 1
  • Initiate, increase dose or frequency, or combine β2-agonists and/or anticholinergics 1
  • Encourage sputum clearance by coughing 1
  • Consider home physiotherapy 1
  • Encourage fluid intake 1
  • Avoid sedatives and hypnotics 1

Hospital Management

• Goals:
  • Evaluate severity, including life-threatening conditions 1
  • Identify the cause of the exacerbation 1
  • Provide controlled oxygenation 1
  • Return the patient to best previous condition 1
• Consider non-invasive ventilation (NIV) as first mode of ventilation for patients with acute respiratory failure 1

Follow-up and Prevention

• Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 1
• After an exacerbation, implement appropriate measures for exacerbation prevention 1
• Consider long-term azithromycin (250 mg three times weekly) in patients with frequent exacerbations, especially those colonized with Pseudomonas aeruginosa 2, 3

Special Considerations

• Sputum cultures are underutilized but should be considered in patients with early treatment failure or repeated exacerbations 4
• Knowledge of local resistance patterns is helpful in directing empirical therapy 1
• Patients with severe COPD or blood eosinophil counts <300 cells/μl may benefit from specific antibiotic regimens 5
• Long-term antibiotic therapy should be used cautiously due to potential development of resistance 6, 2

Common Pitfalls to Avoid

• Failing to differentiate COPD exacerbation from other conditions with similar presentations 1
• Overuse of antibiotics when not indicated (no purulent sputum) 1, 4
• Prolonged corticosteroid courses beyond 5-7 days 1
• Using methylxanthines as first-line bronchodilators due to side effect profile 1
• Not considering sputum cultures in treatment failures or recurrent exacerbations 4