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

Initial Treatment for COPD Exacerbation

Start immediately with short-acting inhaled beta2-agonists (SABAs) combined with short-acting anticholinergics (SAMAs), systemic corticosteroids (40 mg prednisone daily for 5 days), and antibiotics if the patient has increased dyspnea, sputum volume, and sputum purulence. 1, 2

Bronchodilator Therapy (First-Line Treatment)

• Administer short-acting inhaled beta2-agonists with or without short-acting anticholinergics as the initial bronchodilators upon arrival 1, 2

• For moderate exacerbations, either a beta-agonist or anticholinergic can be given via nebulizer 1

• For severe exacerbations or poor response to monotherapy, combine both SABA and SAMA together 1

• Nebulized bronchodilators should be given at 4-6 hourly intervals but may be used more frequently if needed 1

Systemic Corticosteroids (Essential Component)

• Administer 40 mg prednisone per day for exactly 5 days 1, 2

• Systemic glucocorticoids improve lung function, oxygenation, shorten recovery time, and reduce hospitalization duration 1, 2

• Duration should not exceed 5-7 days 1

Antibiotic Therapy (When Indicated)

Antibiotics are indicated when patients present with at least two of three cardinal symptoms:

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence 1, 2

Antibiotic selection:

• First-line: Amoxicillin or tetracycline for mild exacerbations 2
• Amoxicillin-clavulanate for moderate to severe exacerbations 2
• Azithromycin 500 mg daily for 3 days is effective (clinical cure rate 85% at Day 21-24) 3
• Duration: 5-7 days 1, 2

Oxygen Therapy (For Hypoxemic Patients)

• Target SpO2 ≥90% (or PaO2 ≥6.6 kPa) without causing respiratory acidosis 1, 2

• In known COPD patients aged 50+ years, start with FiO2 ≤28% via Venturi mask or 2 L/min via nasal cannula until arterial blood gases are obtained 1, 2

• Controlled oxygen therapy prevents CO2 retention and respiratory acidosis 4

Noninvasive Ventilation (For Acute Respiratory Failure)

• Consider NIV for patients with acute respiratory failure, as it improves gas exchange, reduces work of breathing, decreases hospitalization duration, and improves survival 1, 2

• NIV is standard therapy for COPD exacerbation with respiratory failure and is supported by clinical practice guidelines 4

Initial Investigations

Obtain immediately:

• Arterial blood gas analysis
• Chest radiograph
• Complete blood count
• Electrolytes
• ECG 1

Treatment Algorithm Summary

For ALL COPD exacerbations:

1. Short-acting bronchodilators (SABA ± SAMA) immediately 1, 2
2. Systemic corticosteroids (40 mg prednisone × 5 days) 1, 2

Add antibiotics (5-7 days) if:

• Purulent sputum present 1
• At least 2 of 3 cardinal symptoms present 2

Add controlled oxygen if:

• SpO2 <90% (target 88-92%) 1, 2, 4

Add NIV if:

• Acute respiratory failure develops 1, 2