What is the next step in managing a 54-year-old female with chronic obstructive pulmonary disease (COPD) exacerbation, who has completed a course of Zithromax (azithromycin) and still presents with increased sputum production and cough?

From the Guidelines

For a 54-year-old female with COPD exacerbation who has completed azithromycin but still has increased sputum and persistent cough, I recommend adding a short course of oral corticosteroids such as prednisone 40mg daily for 5 days. This approach is supported by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report, which suggests that systemic glucocorticoids in COPD exacerbations shorten recovery time and improve FEV1 1. The use of oral corticosteroids can help reduce airway inflammation that may be perpetuating symptoms despite antibiotic therapy.

Additionally, it is crucial to ensure the patient is using her rescue inhaler (albuterol) as needed and optimizing her maintenance inhalers, which typically include a long-acting bronchodilator and inhaled corticosteroid combination, as recommended by the GOLD executive summary 1. Consider adding a short-acting anticholinergic like ipratropium bromide via nebulizer or inhaler for additional bronchodilation. Increased airway clearance techniques such as controlled coughing, chest physiotherapy, or using devices like an Acapella or Flutter valve may help clear retained secretions. Adequate hydration (2-3 liters of fluid daily) will help thin secretions.

Key considerations in managing this patient include:

• Optimizing bronchodilation with short-acting and long-acting agents
• Reducing airway inflammation with corticosteroids
• Enhancing airway clearance
• Ensuring adequate hydration If symptoms persist beyond 1-2 weeks despite these interventions, the patient should return for reevaluation as she may need a different antibiotic if there's a resistant organism, or may have developed a secondary infection or other complications requiring further investigation, in line with the principles outlined in the management of COPD exacerbations 1.

From the FDA Drug Label

Azithromycin Tablets, USP are indicated for the treatment of patients with mild to moderate infections (pneumonia: see WARNINGS) caused by susceptible strains of the designated microorganisms in the specific conditions listed below Adults Acute bacterial exacerbations of chronic obstructive pulmonary disease due to Haemophilus influenzae, Moraxella catarrhalis or Streptococcus pneumoniae

The patient has completed a course of Zithromax (azithromycin) and still presents with increased sputum production and cough, indicating that the treatment may not have been effective.

• Next steps could include:
  • Re-evaluating the patient to determine if the exacerbation is due to a different cause or if the patient has developed a resistance to azithromycin.
  • Considering alternative treatments, such as a different antibiotic or adding other medications to help manage the patient's symptoms.
  • Consulting with a specialist, such as a pulmonologist, to determine the best course of treatment for the patient. 2

From the Research

Next Steps in Managing COPD Exacerbation

The patient has completed a course of Zithromax (azithromycin) and still presents with increased sputum production and cough. The next steps in management can be considered as follows:

• Assess the severity of the exacerbation: According to 3, the etiology of the exacerbations is mainly infectious (up to 80%). Other conditions such as heart failure, pulmonary embolism, nonpulmonary infections, and pneumothorax can mimic an acute exacerbation or possibly act as "triggers."
• Consider additional therapies: As mentioned in 4, treatment with augmented penicillins, fluoroquinolones, third-generation cephalosporins or aminoglycosides may be considered in patients with more severe exacerbations.
• Systemic corticosteroids: 3 suggests that steroids do improve several outcomes during an acute COPD exacerbation, and a 10- to 14-day course seems appropriate.
• Non-invasive ventilation: As stated in 3, noninvasive positive pressure ventilation might benefit a group of patients with rapid decline in respiratory function and gas exchange.
• Re-evaluate the patient's condition: According to 5, the complexity of worsening dyspnea has suggested a need to improve the definition of ECOPD using objective measurements such as blood counts and C-reactive protein to improve accuracy of diagnosis and a personalized approach to management.
• Consider long-term prevention strategies: As mentioned in 5, dual bronchodilators reduce exacerbation frequency but in patients with continuing exacerbations, triple therapy should be considered, especially if blood eosinophils are elevated.
• Monitor for potential side effects: As stated in 6, inhaled beta-2 agonists occasionally provoke cardiovascular disorders, and there is little evidence that ipratropium, an inhaled short-acting anti-muscarinic bronchodilator, improves COPD symptoms.