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

Management of COPD Exacerbation in the Emergency Room

The management of COPD exacerbation in the emergency room should follow a structured approach focusing on oxygen therapy, bronchodilators, corticosteroids, antibiotics, and ventilatory support as needed, with careful titration of oxygen to maintain saturations between 88-92% to prevent respiratory acidosis.

Initial Assessment

• Evaluate for signs of significant deterioration: increased dyspnea, increased sputum volume, purulent sputum, wheeze, tachypnea, use of accessory muscles, peripheral edema, cyanosis, and confusion 1
• Obtain arterial blood gas analysis (noting FiO2), chest radiograph, full blood count, urea and electrolytes, and ECG 2
• Record initial FEV1 and/or peak flow when possible 2
• Send sputum for culture if purulent; consider blood cultures if pneumonia is suspected 2

Oxygen Therapy

• Target oxygen saturation of 88-92% to improve hypoxemia without causing carbon dioxide retention 2, 1
• In patients with known COPD aged 50 years or more, initially use controlled oxygen therapy with FiO2 ≤28% via Venturi mask or ≤2 L/min via nasal cannulae until arterial blood gases are known 2
• Check blood gases within 60 minutes of starting oxygen and within 60 minutes of any change in inspired oxygen concentration 2
• If PaO2 is responding and pH remains stable, gradually increase oxygen concentration until PaO2 is above 7.5 kPa 2
• Higher oxygen saturations (>92%) are associated with increased mortality, even in normocapnic patients 3

Bronchodilator Therapy

• Administer nebulized bronchodilators immediately on arrival and at 4-6 hourly intervals thereafter 2
• For moderate exacerbations: use either a beta-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) or an anticholinergic (ipratropium bromide 0.25-0.5 mg) 2
• For severe exacerbations: use both beta-agonists and anticholinergics 2, 1
• In patients with respiratory acidosis or raised PaCO2, use compressed air to drive nebulizers with supplemental oxygen via nasal cannulae (1-2 L/min) during nebulization 2
• After 24-48 hours or when clinical improvement occurs, transition to metered dose inhalers or dry powder inhalers 2

Corticosteroid Therapy

• Administer systemic corticosteroids to all patients with COPD exacerbation 1
• Use oral prednisolone 30-40 mg daily for 5-7 days 2, 1
• If oral route is not possible, use intravenous hydrocortisone 100 mg 2
• Discontinue corticosteroids after the acute episode (usually 7-14 days) unless specifically indicated for long-term treatment 2

Antibiotic Therapy

• Provide antibiotics when patients present with at least two of the following: increased dyspnea, increased sputum volume, and purulent sputum 2, 1
• Antibiotics reduce the risk of short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 2
• First-line options: amoxicillin or tetracycline (unless used with poor response prior to admission) 2
• Second-line options for severe exacerbations: broad-spectrum cephalosporins, newer macrolides (e.g., azithromycin 500 mg daily for 3 days) 2, 4
• Recommended duration of antibiotic therapy is 5-7 days 2
• For patients with frequent exacerbations, severe airflow limitation, or requiring mechanical ventilation, obtain sputum cultures to identify resistant pathogens 2

Ventilatory Support

• Consider non-invasive ventilation (NIV) as the first mode of ventilation for patients with acute respiratory failure 2, 1
• NIV reduces mortality and intubation rates by 80-85% 2
• Indications for NIV include persistent hypoxemia despite supplemental oxygen, respiratory acidosis (pH <7.35), or severe dyspnea with signs of respiratory muscle fatigue 1
• Consider invasive mechanical ventilation if NIV fails 2
• In patients who fail NIV as initial therapy and require invasive ventilation, expect increased morbidity, longer hospital stay, and higher mortality 2

Additional Measures

• Consider diuretics if peripheral edema and raised jugular venous pressure are present 2
• Consider intravenous methylxanthines (aminophylline 0.5 mg/kg/hour) by continuous infusion if response to nebulized bronchodilators is poor, but monitor blood levels daily 2, 5
• Prophylactic subcutaneous heparin is recommended for patients with acute-on-chronic respiratory failure 2

Discharge Planning and Follow-up

• Arrange early follow-up (<30 days) after discharge to review discharge therapy and make necessary changes 2
• Additional follow-up at 3 months is recommended to ensure return to stable state 2
• Consider early pulmonary rehabilitation (within 3 weeks after discharge) 1
• Review smoking status, inhaler technique, and maintenance medications 1

Common Pitfalls and Caveats

• Avoid prolonged courses of systemic corticosteroids beyond 5-7 days due to increased risk of adverse effects 1
• Avoid high-flow oxygen therapy in COPD patients as it can worsen hypercapnia and respiratory acidosis 6, 3
• Recognize that methylxanthines (theophylline) have limited efficacy and potential side effects; use only if response to other bronchodilators is poor 1, 5
• Be aware that failure to recognize COPD in patients presenting with respiratory symptoms can lead to inappropriate oxygen therapy 6