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

Treatment for COPD Exacerbation

For COPD exacerbations, the recommended treatment includes short-acting bronchodilators, systemic corticosteroids for 5 days, and antibiotics when indicated by increased sputum purulence with either increased dyspnea or sputum volume. 1, 2

Initial Management

• Short-acting inhaled beta2-agonists (SABAs), with or without short-acting anticholinergics (SAMAs), are the initial bronchodilators of choice for acute exacerbation treatment 1, 2
• For moderate exacerbations, either a beta-agonist or an anticholinergic can be given via nebulizer 1
• For severe exacerbations, both SABA and SAMA should be administered together for maximum bronchodilation 1, 2
• Nebulized bronchodilators should be given upon arrival and at 4-6 hourly intervals thereafter, with more frequent administration if required 1

Systemic Corticosteroids

• Systemic glucocorticoids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1, 2
• A dose of 40 mg prednisone per day for 5 days is recommended 1, 2
• Duration of therapy should not exceed 5-7 days 1, 2
• Oral prednisolone is equally effective to intravenous administration 2

Antibiotic Therapy

• 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 1, 2
• First-line antibiotics include aminopenicillins with clavulanic acid, macrolides, or tetracyclines based on local bacterial resistance patterns 1, 2
• For acute bacterial exacerbations, azithromycin (500 mg once daily for 3 days) has shown similar efficacy to longer courses of other antibiotics 3

Oxygen Therapy

• The aim of oxygen therapy is to achieve a SpO2 ≥90% without causing respiratory acidosis 1
• In patients with known COPD aged 50 years or older, initial FiO2 should not exceed 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known 1

Treatment Setting and Classification

• More than 80% of exacerbations can be managed on an outpatient basis 2
• Hospitalization should be considered for severe exacerbations, particularly with acute respiratory failure 2
• Mild exacerbations can be treated with short-acting bronchodilators only 2
• Moderate exacerbations require short-acting bronchodilators plus antibiotics and/or oral corticosteroids 2
• Severe exacerbations require hospitalization or emergency room visit and may be associated with acute respiratory failure 2

Respiratory Support for Severe Exacerbations

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

Post-Exacerbation Management

• Maintenance therapy with long-acting bronchodilators should be initiated before hospital discharge 2
• For stable COPD, guidelines recommend maintenance therapy with either:
  • Long-acting muscarinic antagonist (LAMA) monotherapy 4
  • Combination inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) therapy 4
  • LAMA/LABA combination therapy 4
• For patients with frequent exacerbations (≥2 per year), more aggressive preventive strategies are needed 2
• In patients with moderate to severe COPD, combination therapy has shown greater efficacy in preventing exacerbations than monotherapy 4

Common Pitfalls and Caveats

• Overuse of oxygen therapy can lead to respiratory acidosis in COPD patients; titrate carefully to SpO2 ≥90% 1
• Corticosteroids should be limited to 5-7 days to minimize adverse effects 1, 2
• Antibiotics should not be prescribed routinely for all exacerbations but only when indicated by increased sputum purulence plus either increased dyspnea or sputum volume 2
• Intravenous methylxanthines (theophylline) are not recommended due to their increased side effect profile 2
• ICS therapy may increase the risk of pneumonia in COPD patients, which should be carefully considered when assessing the risk/benefit ratio of ICS/LABA combinations 4