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

Treatment of COPD Exacerbations

The recommended first-line treatment for COPD exacerbations includes short-acting bronchodilators (beta2-agonists with or without anticholinergics), systemic corticosteroids for 5-7 days, and antibiotics when indicated by increased sputum purulence or signs of infection. 1

Initial Assessment and Management

• COPD exacerbations present as worsening of previous stable situation with increased dyspnea, sputum volume, sputum purulence, wheeze, and chest tightness 2
• Differential diagnoses to consider include pneumonia, pneumothorax, left ventricular failure, pulmonary embolus, lung cancer, and upper airway obstruction 2
• Decision to treat at home or hospital depends on severity of symptoms, presence of respiratory failure, and comorbidities 2

Bronchodilator Therapy

• Short-acting inhaled beta2-agonists (SABA) with or without short-acting anticholinergics (SAMA) are the initial bronchodilators of choice 2, 1
• 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 given via nebulizer 2
• For severe exacerbations, both SABA and SAMA should be administered together 2, 1
• Nebulized bronchodilators should be given upon arrival and at 4-6 hourly intervals, 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 prednisone 40 mg daily 1, 3
• Longer courses (10-14 days) show no additional benefit but increase risk of adverse effects 4, 3
• The REDUCE trial demonstrated that 5-day treatment with prednisone was noninferior to 14-day treatment regarding reexacerbation within 6 months 3
• Tapering is generally unnecessary for short courses of corticosteroids 5

Antibiotic Therapy

• Antibiotics should be given when there are two or more of: increased breathlessness, increased sputum volume, or development of purulent sputum 2, 1
• First-line antibiotics include amoxicillin, doxycycline, or trimethoprim-sulfamethoxazole 6
• The recommended duration of antibiotic therapy is 5-7 days 1
• For severe exacerbations or treatment failure, consider augmented penicillins, fluoroquinolones, or third-generation cephalosporins 6

Oxygen Therapy

• The aim of oxygen therapy is to achieve an oxygen saturation (SpO2) ≥90% without causing respiratory acidosis 1
• In patients with known COPD, initial oxygen therapy should be controlled (24-28% via Venturi mask or 1-2 L/min via nasal cannula) until arterial blood gases are known 1
• In patients with hypercapnia or respiratory acidosis, oxygen therapy should be carefully titrated 2

Additional Treatments

• Consider intravenous methylxanthines (aminophylline 0.5 mg/kg/hour) by continuous infusion if the patient is not responding to other treatments, though evidence for effectiveness is limited 2, 6
• Diuretics are indicated if there is peripheral edema and a raised jugular venous pressure 2
• Prophylactic subcutaneous heparin is recommended for patients with acute respiratory failure 2

Ventilatory Support

• Non-invasive ventilation (NIV) should be considered for patients with acute respiratory failure (pH <7.26 and rising PaCO2) who fail to respond to initial therapy 2, 1
• NIV improves gas exchange, reduces work of breathing, decreases hospitalization duration, and improves survival 1
• Invasive mechanical ventilation should be considered when NIV fails or is contraindicated 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
• Review the patient's inhaler technique, smoking status, and consider pulmonary rehabilitation 2

Common Pitfalls and Caveats

• Overuse of oxygen therapy in COPD patients can lead to hypercapnia; use controlled oxygen therapy 1
• Methylxanthines are not recommended as first-line therapy due to potential side effects 2
• Chest physiotherapy is not routinely recommended for acute exacerbations of COPD 2
• Patients with frequent exacerbations may benefit from maintenance therapy with inhaled corticosteroids and long-acting bronchodilators to reduce future exacerbation risk 7
• Monitoring for hyperglycemia and hypertension is important during corticosteroid therapy, though short courses have fewer adverse effects 3