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

Treatment for COPD Exacerbation

The standard treatment for COPD exacerbation includes short-acting bronchodilators (SABAs with or without anticholinergics), systemic corticosteroids (40mg prednisone daily for 5 days), and antibiotics when indicated by increased sputum purulence plus either increased dyspnea or sputum volume. 1

Initial Assessment and Classification

• COPD exacerbations are classified as mild, moderate, or severe, which guides treatment intensity and setting 1
• More than 80% of exacerbations can be managed on an outpatient basis 1
• Hospitalization should be considered for severe exacerbations, particularly those with acute respiratory failure 1

Pharmacological Management

Bronchodilator Therapy

• Short-acting inhaled β2-agonists (SABAs), with or without short-acting anticholinergics, are the initial bronchodilators of choice for acute treatment 1
• Either metered-dose inhalers (with spacers) or nebulizers can be used effectively, though nebulizers may be easier for sicker patients 1
• The combination of ipratropium and albuterol is more effective than either agent alone, with greater improvements in FEV1 2

Corticosteroid Therapy

• Systemic glucocorticoids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1
• A dose of 40 mg prednisone per day for 5 days is recommended (duration should not exceed 5-7 days) 1
• Oral prednisolone is equally effective to intravenous administration 1
• Corticosteroids may be less efficacious in patients with lower blood eosinophil levels 1

Antibiotic Therapy

• Antibiotics should be given when there is increased sputum purulence plus either increased dyspnea or increased sputum volume 1
• Antibiotics reduce the risk of short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1
• The recommended duration of antibiotic therapy is 5-7 days 1
• Antibiotic choice should be based on local bacterial resistance patterns; initial empirical treatment typically includes an aminopenicillin with clavulanic acid, a macrolide, or a tetracycline 1

Respiratory Support for Severe Exacerbations

• For severe exacerbations with acute respiratory failure, noninvasive ventilation (NIV) should be the first mode of ventilation for patients who have no absolute contraindication 1
• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization duration, and improves survival 1
• Targeted oxygen therapy should be titrated to an SpO2 of 88-92% to improve outcomes 3

Medications to Avoid or Use with Caution

• Intravenous methylxanthines (theophylline) are not recommended due to increased side effect profiles 1
• Roflumilast is indicated for reducing the risk of COPD exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations, but is not indicated for the relief of acute bronchospasm during an exacerbation 4

Follow-up After Exacerbation

• Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 1
• A follow-up visit after an acute exacerbation provides an opportunity to help the patient plan for future exacerbation prevention 1
• At 8 weeks after an exacerbation, 20% of patients have not recovered to their pre-exacerbation state, highlighting the importance of follow-up care 1

Common Pitfalls to Avoid

• Failing to provide antibiotics when indicated (increased sputum purulence plus either increased dyspnea or increased sputum volume) 1
• Using intravenous corticosteroids when oral administration is equally effective 1, 5
• Prolonging corticosteroid treatment beyond 5-7 days, which increases risk of side effects without additional benefit 1
• Using theophylline, which provides little additional benefit in patients receiving inhaled bronchodilators and adequate corticosteroids 6
• Failing to initiate maintenance therapy before discharge to prevent future exacerbations 1