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

Treatment of COPD Exacerbations

The treatment of COPD exacerbations should include short-acting inhaled beta2-agonists (SABAs) with or without short-acting anticholinergics, systemic corticosteroids for 5 days, and antibiotics when indicated by increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2

Initial Management

• Short-acting inhaled beta2-agonists (SABAs), with or without short-acting anticholinergics, are the first-line bronchodilators for treating acute exacerbations 3, 1
• Either metered-dose inhalers (with spacers) or nebulizers can be used effectively, though nebulizers may be easier for sicker patients 1
• For moderate exacerbations, either a beta-agonist or an anticholinergic drug should be given via nebulizer 2
• For severe exacerbations, both SABA and short-acting anticholinergics should be administered together 2

Systemic Corticosteroids

• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 3, 1
• A dose of 40 mg prednisone per day for 5 days is recommended 1, 4
• Short-duration therapy (5 days) is as effective as conventional longer-duration therapy (10-14 days) with significantly reduced glucocorticoid exposure 4, 5
• Oral prednisolone is equally effective to intravenous administration for most patients 1
• Corticosteroids may be less efficacious in patients with lower blood eosinophil levels 1

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% 1
• The recommended duration of antibiotic therapy is 5-7 days 1, 2
• First-line antibiotics include amoxicillin, tetracycline, or macrolides unless used with poor response prior to admission 2, 6
• For more severe exacerbations, consider augmented penicillins, fluoroquinolones, or third-generation cephalosporins 6

Oxygen Therapy

• The aim of oxygen therapy is to achieve a SpO2 ≥90% without causing respiratory acidosis 2
• 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 2

Treatment Setting and Classification

• COPD exacerbations are classified as 3:

  • 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; may be associated with acute respiratory failure)

• More than 80% of exacerbations can be managed on an outpatient basis 1

• Hospitalization should be considered for severe exacerbations, particularly with acute respiratory failure 1

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 3, 1
• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization duration, and improves survival 1
• Methylxanthines (theophylline) are not recommended due to increased side effect profiles 3, 1

Follow-up After Exacerbation

• Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 3, 1
• At 8 weeks after an exacerbation, 20% of patients have not recovered to their pre-exacerbation state, highlighting the importance of follow-up care 3, 1
• Patients with frequent exacerbations (≥2 per year) have worse health status and morbidity, requiring more aggressive preventive strategies 3, 1

Prevention of Future Exacerbations

• For maintenance therapy in stable COPD, consider long-acting muscarinic antagonist (LAMA) monotherapy, combination inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) therapy, or LAMA/LABA combination therapy 1
• Combination therapy has shown greater efficacy in preventing exacerbations than monotherapy in patients with moderate to severe COPD 1
• Wixela Inhub® 250/50 (fluticasone propionate/salmeterol) is indicated for the twice-daily maintenance treatment of airflow obstruction in COPD and to reduce exacerbations in patients with a history of exacerbations 7

Common Pitfalls and Caveats

• Do not exceed recommended corticosteroid duration (5-7 days) as longer courses increase adverse effects without providing additional benefits 5, 4
• Monitor for hyperglycemia when using systemic corticosteroids, especially with parenteral administration 8
• Do not use methylxanthines (theophylline) routinely due to their side effect profile 3
• Ensure proper inhaler technique when prescribing bronchodilators 3
• Consider comorbidities when diagnosing exacerbations, as symptoms may be due to acute coronary syndrome, heart failure, pulmonary embolism, or pneumonia 3