What is the approach to managing Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

The approach to managing Chronic Obstructive Pulmonary Disease (COPD) exacerbation involves prompt treatment with bronchodilators, systemic corticosteroids, and antibiotics when appropriate, with the goal of minimizing morbidity, mortality, and improving quality of life. For bronchodilation, use short-acting beta-agonists (SABAs) like albuterol 2.5-5mg via nebulizer or 4-8 puffs via MDI every 1-4 hours, often combined with short-acting anticholinergics like ipratropium 0.5mg nebulized or 4-8 puffs via MDI every 4-6 hours, as recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report 1.

Key Components of COPD Exacerbation Management

• Systemic corticosteroids should be administered as prednisone 40mg daily for 5 days or methylprednisolone 40-60mg IV if the patient cannot take oral medications, as they improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1.
• Antibiotics are indicated when there are signs of bacterial infection (increased sputum purulence, volume, or dyspnea); commonly used options include amoxicillin-clavulanate 875/125mg twice daily, doxycycline 100mg twice daily, or azithromycin 500mg on day 1 followed by 250mg daily for 4 days, with the duration of therapy not exceeding 5-7 days 1.
• Supplemental oxygen should be titrated to maintain SpO2 88-92% to prevent hypercapnia while addressing hypoxemia.
• For severe exacerbations, consider non-invasive ventilation (NIV) with BiPAP settings starting at IPAP 10-12 cmH2O and EPAP 4-5 cmH2O, as it improves gas exchange, reduces work of breathing, and the need for intubation, decreases hospitalization duration, and improves survival 1.

Prevention of Future Exacerbations

After stabilization, patients should receive a management plan including:

• Maintenance inhalers
• Smoking cessation support
• Pulmonary rehabilitation referral
• Vaccination updates for influenza and pneumococcal disease to prevent future exacerbations, as preventing exacerbations is a key objective in COPD management and can impact quality of life, progression, and prognosis of COPD 1.

From the Research

Approach to Managing COPD Exacerbation

The approach to managing Chronic Obstructive Pulmonary Disease (COPD) exacerbation involves a combination of pharmacological and non-pharmacological strategies.

• Identifying patients at risk of exacerbations and managing them appropriately to reduce this risk represents an important clinical challenge 2.
• Maximizing bronchodilation as an initial strategy to reduce exacerbation risk is recommended, with the use of long-acting muscarinic antagonist (LAMA)/ long-acting β2-agonist (LABA) in patients assessed as frequent exacerbators (>1 exacerbation/year) 2.
• For patients who continue to experience >1 exacerbation/year despite maximal bronchodilation, treatment should be based on patient phenotype, with consideration of adding inhaled corticosteroids (ICS) to a LABA/LAMA combination in exacerbating patients who have an asthma-COPD overlap syndrome or high blood eosinophil counts 2.
• Pulmonary rehabilitation should be included as part of a comprehensive management plan for all patients at risk of exacerbations 2, 3.

Pharmacological Strategies

Pharmacological strategies for managing COPD exacerbations include:

• Bronchodilators, such as short-acting beta 2-agonists or anticholinergics, which are the preferred agents for relieving dyspnea 4, 5.
• Corticosteroids, which have been shown to improve outcomes during an acute COPD exacerbation, with a 10- to 14-day course recommended 4, 5.
• Antibiotics, which are beneficial for patients with severe exacerbation, especially those with purulent sputum, and should be guided by local resistance patterns and the patient's recent history of antibiotic use 4, 5.

Non-Pharmacological Strategies

Non-pharmacological strategies for managing COPD exacerbations include:

• Oxygen administration through a venturi mask, which seems to be appropriate and safe, with oxygen saturation kept just above 90% 4.
• Noninvasive positive pressure ventilation, which may benefit patients with rapid decline in respiratory function and gas exchange, and has the potential to decrease the need for intubation and invasive mechanical ventilation and possibly decrease in-hospital mortality 4, 5.