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

Treatment of COPD Exacerbations

The recommended treatment for COPD exacerbations includes short-acting bronchodilators, systemic corticosteroids (40mg prednisone for 5 days), and antibiotics when indicated by increased sputum purulence, volume, and dyspnea. 1

Initial Assessment and Management

• COPD exacerbations present as worsening of previous stable situation with symptoms including increased sputum purulence, increased sputum volume, increased dyspnea, increased wheeze, chest tightness, and fluid retention 2
• Important differential diagnoses to consider include pneumonia, pneumothorax, left ventricular failure, pulmonary embolus, lung cancer, and upper airway obstruction 2
• Severity classification guides treatment approach:
  • Mild: treated with short-acting bronchodilators only
  • Moderate: treated with short-acting bronchodilators plus antibiotics and/or oral corticosteroids
  • Severe: requires hospitalization or emergency room visit 2

Bronchodilator Therapy

• Short-acting inhaled β2-agonists (SABA), with or without short-acting anticholinergics (SAMA), are recommended as the initial bronchodilators 1
• For moderate exacerbations, either a β-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) or an anticholinergic drug (ipratropium bromide 0.25-0.5 mg) should be administered via nebulizer 2
• For severe exacerbations, or if response to either treatment alone is poor, both should be administered together 2, 1
• Nebulized bronchodilators should be given upon arrival and at 4-6 hourly intervals thereafter, but may be used more frequently if required 2

Systemic Corticosteroids

• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 2, 1
• Current evidence supports a 5-day course of 40mg prednisone daily rather than longer traditional 10-14 day courses 3, 1
• The 5-day treatment regimen has been shown to be non-inferior to 14-day treatment with regard to reexacerbation within 6 months of follow-up while significantly reducing glucocorticoid exposure 3
• If the oral route is not possible, 100mg hydrocortisone can be administered intravenously 2

Antibiotic Therapy

• Antibiotics should be given to patients who have all three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence 2, 1
• First-line antibiotics include amoxicillin, tetracycline, or trimethoprim-sulfamethoxazole 4
• For more severe exacerbations, consider augmented penicillins, fluoroquinolones, third-generation cephalosporins, or aminoglycosides 4
• The recommended duration of antibiotic therapy is 5-7 days 1

Oxygen Therapy

• The aim of oxygen therapy is to achieve a PaO2 of at least 6.6 kPa or SpO2 ≥90% without causing respiratory acidosis 1
• In patients with known COPD aged 50 years or older, initial FiO2 should not exceed 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known 1
• For patients receiving nebulized medications, the nebulizer should be driven by compressed air if the PaO2 is raised and/or there is a respiratory acidosis; oxygen can continue via nasal prongs at 1-2 L/min during nebulization 2

Additional Therapies to Consider

• If the patient is not responding to initial bronchodilator therapy, consider intravenous methylxanthines (aminophylline 0.5 mg/kg per hour) by continuous infusion, though evidence for effectiveness is limited 2
• Diuretics are indicated if there is peripheral edema and a raised jugular venous pressure 2
• Non-invasive ventilation (NIV) should be considered for patients with acute respiratory failure with pH <7.26 and rising PaCO2 who fail to respond to supportive treatment and controlled oxygen therapy 2, 1

Hospital vs. Home Management

• Many patients can be managed at home, but some require inpatient support 2
• Factors suggesting need for hospitalization include:
  • Marked increase in intensity of symptoms
  • Severe underlying COPD
  • Onset of new physical signs (e.g., cyanosis, peripheral edema)
  • Failure to respond to initial medical management
  • Significant comorbidities
  • Newly occurring arrhythmias
  • Diagnostic uncertainty
  • Older age
  • Insufficient home support 2

Follow-up After Exacerbation

• Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 2
• After an exacerbation, appropriate measures for exacerbation prevention should be initiated 2
• A further review after an acute exacerbation is merited if the patient fails to respond fully to treatment 2

Common Pitfalls and Caveats

• Avoid prolonged courses of systemic corticosteroids as they increase risk of adverse effects without additional clinical benefit 5, 6
• Tapering of systemic corticosteroid regimens is unnecessary in most circumstances when using short courses (5-7 days) 6
• Chest physiotherapy is not recommended in acute exacerbations of COPD 2
• Methylxanthines (theophylline) are not recommended as first-line therapy due to potential side effects 2, 1
• When using nebulizers with oxygen in patients with COPD and hypercapnia, monitor closely for worsening respiratory acidosis 2