Management of Acute Exacerbation of COPD
The management of acute exacerbation of COPD requires prompt treatment with short-acting bronchodilators, systemic corticosteroids for 5-7 days, and antibiotics when indicated by increased sputum purulence or volume. 1, 2
Assessment and Diagnosis
- AECOPD presents as worsening of previous stable condition with increased sputum purulence/volume, increased dyspnea, increased wheeze, chest tightness, and/or fluid retention 2
- Important differential diagnoses to consider include pneumonia, pneumothorax, left ventricular failure, pulmonary embolus, lung cancer, and upper airway obstruction 1
- Classify exacerbations 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, may be associated with acute respiratory failure) 1
Treatment Approach
Bronchodilators
- Short-acting inhaled β2-agonists with or without short-acting anticholinergics are the initial bronchodilators recommended 1
- Metered dose inhalers (with or without spacer) or nebulizers can be used with similar efficacy, though nebulizers may be easier for sicker patients 1
- Ensure patient can use the delivery device effectively 1
Systemic Corticosteroids
- Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1
- Recommended dose is 40 mg prednisone daily for 5 days - shorter courses (5 days) are as effective as longer courses (14 days) with less cumulative steroid exposure 1, 3
- Oral prednisolone is equally effective to intravenous administration 1
- Recent evidence strongly supports that 5-day treatment with systemic glucocorticoids is noninferior to 14-day treatment regarding reexacerbation within 6 months 3
Antibiotics
- Indicated when two or more of the following are present: increased breathlessness, increased sputum volume, or development of purulent sputum 1, 2
- Antibiotics shorten recovery time and reduce risk of early relapse, treatment failure, and hospitalization duration 1
- Duration of antibiotic therapy should be 5-7 days 1, 2
Management Based on Setting
Outpatient Management
- For mild to moderate exacerbations:
Hospital Management
- For severe exacerbations:
- Continue all outpatient treatments 1
- Provide controlled oxygen therapy to maintain oxygen saturation without causing respiratory acidosis 2
- Consider non-invasive ventilation (NIV) as first mode of ventilation for patients with acute respiratory failure 1
- Intravenous methylxanthines are not recommended due to increased side effect profiles 1
- Consider diuretics if peripheral edema is present 2
- Consider prophylactic subcutaneous heparin 2
Follow-up Care
- Review after an acute exacerbation to assess response to treatment 1
- Use follow-up visit to plan for future and prevent further exacerbations 1
- Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 1
- Provide advice on smoking cessation, lifestyle, activity levels, and weight 1
Common Pitfalls and Caveats
- Avoid prolonged courses of systemic corticosteroids - evidence shows 5-day courses are as effective as longer courses with fewer side effects 4, 3
- Standardized order sets in electronic health systems can help reduce steroid dose and length of hospital stay 5
- Interprofessional education can improve adherence to guideline-based therapy and reduce excessive corticosteroid dosing 6
- Methylxanthines should not be used as first-line therapy due to side effects 1
- Consider patient's comorbidities when selecting treatments, especially in elderly patients with multiple conditions 2