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

Treatment of COPD Exacerbation

The treatment of COPD exacerbation should include short-acting bronchodilators, systemic corticosteroids for 5 days, and antibiotics when indicated, with consideration for hospitalization and respiratory support in severe cases. 1, 2

Classification of Exacerbations

• COPD exacerbations are classified as mild (treated with short-acting bronchodilators only), moderate (treated with short-acting bronchodilators plus antibiotics and/or oral corticosteroids), or severe (requiring hospitalization or emergency room visit) 1, 2
• More than 80% of exacerbations can be managed on an outpatient basis 2
• Exacerbations are mainly triggered by respiratory viral infections, bacterial infections, and environmental factors 1

Initial Assessment

• Key symptoms of exacerbation include increased dyspnea (the cardinal symptom), increased sputum purulence and volume, increased cough, and wheeze 1, 3
• Differential diagnoses that must be excluded include pneumonia, pneumothorax, left ventricular failure/pulmonary edema, pulmonary embolism, and lung cancer 1, 3
• Chest radiography is essential to exclude alternative diagnoses in uncertain cases 3

Pharmacological Management

Bronchodilators

• Short-acting inhaled β2-agonists (SABAs), with or without short-acting anticholinergics, are recommended as the initial bronchodilators for acute treatment 1, 2
• Either metered-dose inhalers (with spacers) or nebulizers can be used effectively, though nebulizers may be easier for sicker patients 2
• Methylxanthines (theophylline) are not recommended due to increased side effect profiles 1, 2

Systemic Corticosteroids

• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1, 2
• A 5-day course of prednisone 40 mg daily is recommended and has been shown to be non-inferior to longer 14-day courses 2, 4
• Short-duration corticosteroid treatment (5 days) significantly reduces glucocorticoid exposure without increasing the risk of treatment failure or relapse compared to longer courses 5, 4
• Oral prednisolone is equally effective to intravenous administration 2
• Tapering of systemic corticosteroid regimens is unnecessary in most circumstances when using short courses 6

Antibiotics

• Antibiotics should be given when there is increased sputum purulence plus either increased dyspnea or increased sputum volume 1, 2
• Antibiotics reduce the risk of short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 2
• The recommended duration of antibiotic therapy is 5-7 days 2
• 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 2

Management Based on Severity

Mild Exacerbations

• Treat with short-acting bronchodilators only 1, 2
• Follow-up to ensure resolution of symptoms 1

Moderate Exacerbations

• Treat with short-acting bronchodilators plus antibiotics and/or oral corticosteroids 1, 2
• Oral corticosteroids (prednisone 40 mg daily for 5 days) 2, 4
• Antibiotics if purulent sputum is present 1, 2

Severe Exacerbations

• Require hospitalization or emergency room visit 1, 2
• May be associated with acute respiratory failure 1
• Noninvasive ventilation (NIV) should be the first mode of ventilation for patients with acute respiratory failure who have no absolute contraindication 2
• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization duration, and improves survival 2

Follow-up After Exacerbation

• Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 1, 2
• Wixela Inhub 250/50 (fluticasone propionate/salmeterol) is indicated for maintenance treatment of COPD and to reduce exacerbations in patients with a history of exacerbations 7
• Follow-up visit after an acute exacerbation provides an opportunity to help the patient plan for future exacerbation prevention 1, 2
• 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, 2

Prevention of Future Exacerbations

• Patients with frequent exacerbations (≥2 per year) have worse health status and morbidity, requiring more aggressive preventive strategies 1, 2, 8
• Combination therapy with inhaled corticosteroids and long-acting bronchodilators has been shown to reduce exacerbation frequency 7, 8, 9
• Non-pharmacological approaches including smoking cessation, pulmonary rehabilitation, and self-management are important components of exacerbation prevention 8, 9