Is adrenaline recommended as a first-line treatment for chronic obstructive pulmonary disease (COPD) exacerbation?

Adrenaline (Epinephrine) is NOT Recommended for COPD Exacerbations

Adrenaline (epinephrine) is not recommended as a first-line treatment for COPD exacerbations. Short-acting inhaled beta2-agonists (salbutamol/terbutaline) with or without short-acting anticholinergics (ipratropium) are the recommended initial bronchodilators for treating COPD exacerbations. 1

First-Line Bronchodilator Therapy for COPD Exacerbations

• For moderate exacerbations, 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) should be administered via nebulizer 2
• For severe exacerbations or poor response to monotherapy, both beta-agonists and anticholinergics should be administered together 2, 1
• Nebulized bronchodilators should be given upon arrival and at 4-6 hourly intervals thereafter, with more frequent administration if required 2
• In patients with COPD, nebulizers should be powered by compressed air rather than oxygen if the patient has elevated PaCO2 or respiratory acidosis 2

Additional Standard Treatments for COPD Exacerbations

• Systemic corticosteroids (preferably oral) for 5-7 days to reduce recovery time and treatment failure 1, 3
• Antibiotics when signs of bacterial infection are present (increased sputum purulence, volume, or dyspnea) 1
• Controlled oxygen therapy for hypoxemic patients (target saturation 88-92%) 1
• For patients not responding to standard therapy, intravenous methylxanthines (aminophylline) may be considered, though evidence for their effectiveness is limited 2

Management of Respiratory Failure

• For patients with acute respiratory failure (pH <7.26 and rising PaCO2), noninvasive ventilation (NIV) should be considered 2
• NIV improves gas exchange, reduces work of breathing, decreases hospitalization duration, and improves survival 1
• NIV is most effective when initiated early in the course of respiratory failure 2

Important Considerations and Pitfalls

• Avoid high-concentration oxygen therapy in COPD patients; do not exceed 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known 2
• Monitor arterial blood gases within 60 minutes of starting oxygen therapy and after any change in oxygen concentration 2
• Antitussives are not recommended in COPD management as they may interfere with airway clearance mechanisms 3
• Cough suppressants lack sufficient evidence of benefit and may potentially worsen respiratory status by causing retention of secretions 3

Follow-up Care

• Bronchodilators can be switched from nebulized to metered-dose inhalers or dry powder inhalers once the patient is clinically improving 2
• Pulmonary rehabilitation should be initiated within 3 weeks after hospital discharge 1
• Systemic corticosteroids should be discontinued after 5-7 days unless there is a specific indication for longer treatment 1

In conclusion, adrenaline (epinephrine) has no established role in the management of COPD exacerbations according to current guidelines. The cornerstone of bronchodilator therapy remains short-acting beta-agonists and anticholinergics, which have demonstrated efficacy and safety in this setting.