What is the management plan for an acute exacerbation of chronic obstructive pulmonary disease (COPD)?

Management of Acute Exacerbation of COPD

The management of acute exacerbation of COPD requires prompt administration of bronchodilators, systemic corticosteroids, and antibiotics when indicated, with consideration for oxygen therapy and ventilatory support in severe cases. 1

Initial Assessment and Triage

• Evaluate severity of exacerbation through signs of infection (pyrexia, purulent sputum), severe airway obstruction (audible wheeze, tachypnea, use of accessory muscles), peripheral edema, cyanosis, and/or confusion 2
• Perform urgent investigations including arterial blood gas measurement (noting FiO2), chest radiograph, full blood count, urea and electrolytes, and ECG 2
• Send sputum for culture if purulent and blood cultures if pneumonia is suspected 2
• Determine appropriate treatment setting (home vs. hospital) based on severity 2

Bronchodilator Therapy

• Administer nebulized bronchodilators immediately upon presentation and continue at 4-6 hourly intervals (may be used more frequently if required) 2
• For moderate exacerbations: use either a beta-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) or an anticholinergic drug (ipratropium bromide 0.25-0.5 mg) 2
• For severe exacerbations: combine both beta-agonist and anticholinergic agents 2, 1
• In patients with raised PaCO2 and/or respiratory acidosis, drive nebulizers with compressed air rather than oxygen, while continuing oxygen via nasal prongs at 1-2 L/min 2
• Continue nebulized bronchodilators for 24-48 hours or until clinical improvement, then transition to metered dose or dry powder inhalers 2

Corticosteroid Therapy

• Administer systemic corticosteroids promptly (prednisolone 30-40 mg daily or 100 mg hydrocortisone if oral route not possible) 2
• Continue treatment for 5-7 days 2, 1
• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 2
• Discontinue after the acute episode unless there is a definite indication for long-term treatment 2

Antibiotic Therapy

• Initiate antibiotics if two or more of the following are present: increased breathlessness, increased sputum volume, or development of purulent sputum 1
• First-line options: amoxicillin or tetracycline (unless used with poor response prior to admission) 2
• Second-line alternatives for more severe exacerbations or lack of response: broad-spectrum cephalosporins or newer macrolides 2
• Duration of antibiotic therapy should be 5-7 days 2, 1
• For acute bacterial exacerbations, azithromycin 500 mg daily for 3 days has shown 85% clinical cure rate 3

Oxygen Therapy

• Target oxygen saturation to achieve PaO2 >7.5 kPa without causing respiratory acidosis 2, 1
• In patients with COPD aged 50 years or more, initially limit FiO2 to 28% via Venturi mask or 2 L/min via nasal cannulae until arterial gas tensions are known 2
• Check blood gases within 60 minutes of starting oxygen and within 60 minutes of changing inspired oxygen concentration 2
• If PaO2 is responding and effect on pH is modest, increase inspired oxygen concentration until PaO2 is above 7.5 kPa 2
• If pH falls (secondary to rise in PaCO2), consider alternative strategies 2

Additional Therapies for Non-Responders

• Consider intravenous methylxanthines (aminophylline 0.5 mg/kg per hour) by continuous infusion if patient is not responding to first-line treatments 2
• Monitor blood levels of theophylline daily if administered 2
• Administer diuretics if peripheral edema and raised jugular venous pressure are present 2, 1
• Provide prophylactic subcutaneous heparin for patients with acute on chronic respiratory failure 2, 1

Ventilatory Support

• Consider ventilatory support (non-invasive or invasive) for patients with pH <7.26 and rising PaCO2 who fail to respond to supportive treatment and controlled oxygen therapy 2, 1
• Non-invasive positive pressure ventilation (NIPPV) has been shown to reduce the need for intubation and length of hospital stay 2
• Decision to institute or withhold ventilatory support should be made by a senior clinician with full information about the patient's premorbid state and wishes 2
• NIPPV is most effective when initiated early; patients with confusion or large volume of secretions are less likely to respond well 2

Home vs. Hospital Management

Home Management (Mild Exacerbations)

• Increase dose or frequency of bronchodilators 2, 1
• Administer antibiotics when indicated 2, 1
• Encourage sputum clearance by coughing and fluid intake 2
• Avoid sedatives and hypnotics 2
• Provide clear instructions on symptoms/signs of worsening and appropriate action 2

Hospital Management (Moderate to Severe Exacerbations)

• Provide all treatments outlined above with close monitoring 1
• Monitor arterial blood gases, especially if initially acidotic or hypercapnic 2
• Repeat blood gas measurements within 60 minutes if clinical situation deteriorates 2
• Chest physiotherapy is not recommended in acute exacerbations of COPD 2, 1

Discharge Planning and Follow-up

• Ensure improvement in symptoms and lung function before discharge 1
• Review medication regimen and consider stepping up maintenance therapy if needed 1
• Schedule follow-up appointment to assess response to treatment and plan for future exacerbation prevention 1
• Provide advice on smoking cessation, lifestyle modifications, and activity levels 1

Common Pitfalls to Avoid

• Administering high-flow oxygen without monitoring blood gases can worsen hypercapnia in COPD patients 2
• Delaying corticosteroid administration can lead to poorer outcomes 2
• Using methylxanthines as first-line therapy increases risk of side effects 2, 1
• Failing to consider ventilatory support early enough in deteriorating patients 2
• Not adjusting nebulizer delivery method in patients with respiratory acidosis (should use compressed air rather than oxygen) 2