What is the management for Chronic Obstructive Pulmonary Disease (COPD) in acute exacerbation?

Management of COPD in Acute Exacerbation

For patients experiencing an acute exacerbation of COPD, treatment should include short-acting bronchodilators, systemic corticosteroids, and antibiotics when indicated, with consideration for oxygen therapy and ventilatory support in severe cases. 1, 2

Initial Assessment and Classification

• An exacerbation of COPD is defined as an acute worsening of respiratory symptoms requiring additional therapy, with key symptoms including increased dyspnea, increased sputum volume, and increased sputum purulence 3, 1
• Exacerbations are classified as:
  • Mild (treated with short-acting bronchodilators only)
  • Moderate (treated with short-acting bronchodilators plus antibiotics and/or oral corticosteroids)
  • Severe (requiring hospitalization or emergency room visit) 3
• Initial investigations should include arterial blood gas analysis, chest radiograph, complete blood count, electrolytes, and ECG 1
• Consider differential diagnoses including pneumonia, pneumothorax, heart failure, pulmonary embolism, lung cancer, and upper airway obstruction 3, 1

Treatment Algorithm

1. Bronchodilator Therapy

• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators 3, 2
• For moderate exacerbations, use a beta-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) or an anticholinergic (ipratropium bromide 0.25-0.5 mg) via nebulizer 3, 1
• For severe exacerbations or poor response to monotherapy, administer both beta-agonists and anticholinergics together 3, 1
• Note that ipratropium as a single agent for acute exacerbations has not been adequately studied, and drugs with faster onset may be preferable as initial therapy 4

2. Systemic Corticosteroids

• Prescribe systemic corticosteroids to reduce clinical failure (weak recommendation, low quality of evidence) 3
• A 5-day course of prednisolone 30-40 mg daily is recommended 1, 2
• Corticosteroids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 3, 1
• If oral route is not possible, 100 mg hydrocortisone can be administered intravenously 3, 1

3. Antibiotic Therapy

• Prescribe systemic antibiotics when patients present with at least two of the following: increased dyspnea, increased sputum volume, and increased sputum purulence (weak recommendation, moderate quality of evidence) 3
• First-line antibiotics include amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid 1, 5
• Choice of antibiotic should be based on local resistance patterns, affordability, and patient history 3
• The recommended duration of antibiotic therapy is 5-7 days 1, 2

4. Oxygen Therapy

• Provide controlled oxygen therapy to maintain PaO2 > 60 mmHg (SpO2 ≥ 90%) without causing respiratory acidosis 1, 2
• In patients over 50 years with known COPD, initial FiO2 should not exceed 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known 3, 1
• Check arterial blood gases within 60 minutes of starting oxygen therapy and after any change in oxygen concentration 1

5. Ventilatory Support

• Consider non-invasive ventilation (NIV) for patients with acute respiratory failure, particularly those with a pH < 7.26 and rising PaCO2 who fail to respond to standard treatment 3, 1
• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospital stay, and improves survival 1, 6
• A pH below 7.26 is predictive of a poor prognosis and may indicate the need for more aggressive intervention 1

6. Additional Considerations

• If the patient does not respond to standard treatments, consider methylxanthines (aminophylline 0.5 mg/kg per hour) as a continuous infusion, though these are generally not recommended due to side effects 3, 1
• Monitor blood levels of theophylline daily if methylxanthines are used 3
• For patients with peripheral edema and raised jugular venous pressure, diuretics are indicated 3

Post-Exacerbation Management

• Initiate maintenance therapy with long-acting bronchodilators before hospital discharge 3, 1
• Consider pulmonary rehabilitation and smoking cessation counseling 1, 7
• Regular follow-up is necessary to monitor symptoms, exacerbations, and lung function 1
• Consider preventive strategies including annual influenza vaccination and pneumococcal vaccination 1, 5

Common Pitfalls and Caveats

• Avoid high-flow oxygen in COPD patients as it may worsen hypercapnia and respiratory acidosis 1
• Do not routinely use chest physiotherapy during acute exacerbations as evidence does not support its use 3
• Recognize that confused patients and those with large volumes of secretions may respond poorly to NIV 3
• Be aware that the decision to use ventilatory support should consider the patient's premorbid state and wishes 3
• Nebulized bronchodilators should be continued for 24-48 hours or until clinical improvement, then transitioned to metered-dose or dry powder inhalers 3