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

COPD Exacerbation Treatment Dot Phrase

The initial treatment for COPD exacerbation should include short-acting inhaled beta2-agonists (SABAs), with or without short-acting anticholinergics (SAMAs), systemic corticosteroids, and antibiotics when indicated. 1

Initial Assessment

• Assess for increased dyspnea, increased sputum volume, and increased sputum purulence (cardinal symptoms) 2
• Evaluate oxygen saturation and consider arterial blood gas analysis for severe exacerbations 2
• Obtain chest radiograph to rule out pneumonia or other complications 1

Bronchodilator Therapy

• Administer short-acting beta2-agonists (e.g., albuterol) via nebulizer or metered-dose inhaler with spacer as first-line treatment 2, 1
• Consider adding ipratropium bromide (anticholinergic) for moderate to severe exacerbations 1, 3
• Nebulized treatments can be given every 4-6 hours or more frequently if needed 1
• Note: Ipratropium bromide alone is not recommended as monotherapy for acute exacerbations 4

Systemic Corticosteroids

• Administer prednisone 40mg orally daily for 5 days 1
• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 2
• Duration should not exceed 5-7 days 2
• IV administration may be considered if patient cannot take oral medications 2

Antibiotic Therapy

• Initiate antibiotics if patient presents with:
  • All three cardinal symptoms (increased dyspnea, sputum volume, and sputum purulence) 2
  • Two cardinal symptoms if increased sputum purulence is one of them 2
  • Requiring mechanical ventilation (invasive or non-invasive) 2
• Recommended antibiotic options:
  • First-line: Amoxicillin, doxycycline, or macrolide 2
  • Second-line: Amoxicillin/clavulanate or respiratory fluoroquinolones 2
  • Duration: 5-7 days 2

Oxygen Therapy

• Titrate supplemental oxygen to maintain SpO2 88-92% 2
• Start with low-flow oxygen (24-28% via Venturi mask or 1-2 L/min via nasal cannula) 1
• Monitor for CO2 retention and worsening acidosis with arterial blood gases after initiating oxygen 2

Ventilatory Support (if needed)

• Consider non-invasive ventilation (NIV) for patients with:
  • Respiratory acidosis (pH < 7.35 with PaCO2 > 45 mmHg) 2
  • Severe dyspnea with signs of respiratory muscle fatigue 2
• NIV reduces mortality and intubation rates with success rates of 80-85% 2

Discharge Planning

• Ensure appropriate inhaler technique before discharge 2
• Schedule follow-up within 30 days of discharge 2
• Consider pulmonary rehabilitation referral 5
• Review maintenance medications to prevent future exacerbations 2, 6

Prevention of Future Exacerbations

• Long-acting bronchodilators (LAMA/LABA) reduce exacerbation risk 2, 6
• Consider adding inhaled corticosteroids for patients with blood eosinophilia or asthma-COPD overlap 6
• Smoking cessation counseling 2, 7
• Influenza and pneumococcal vaccination 7