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

Treatment of COPD Exacerbation

For patients experiencing a COPD exacerbation, initiate treatment with short-acting bronchodilators (β2-agonists with or without anticholinergics), systemic corticosteroids (prednisone 40 mg daily for 5 days), and antibiotics if there is increased sputum purulence. 1

Bronchodilator Therapy

Short-acting inhaled β2-agonists (with or without short-acting anticholinergics) are the cornerstone of acute exacerbation management and should be started immediately. 1

• Delivery can be via metered-dose inhaler with spacer or nebulizer—both are equally effective, though nebulizers may be easier for severely dyspneic patients 1
• There is no significant difference in FEV1 improvement between delivery methods 1
• Consider adding a long-acting bronchodilator if the patient is not already using one 2
• Avoid intravenous methylxanthines due to increased side effects without additional benefit 1, 2

Systemic Corticosteroids

Administer prednisone 40 mg orally daily for 5 days—this is the evidence-based regimen that improves lung function, oxygenation, and reduces recovery time. 1

• Oral administration is equally effective as intravenous 1
• Treatment duration should not exceed 5-7 days 1
• Corticosteroids shorten recovery time, improve FEV1, reduce risk of early relapse and treatment failure, and decrease hospitalization length 1
• May be less effective in patients with lower blood eosinophil levels 1

Antibiotic Therapy

Prescribe antibiotics when patients present with increased sputum purulence and/or increased sputum volume—this indicates bacterial infection. 1, 2

• First-line options include amoxicillin/ampicillin, cephalosporins, doxycycline, or macrolides 2
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1
• Duration should be 5-7 days 1
• The classic indication is presence of two or more cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence 1
• Azithromycin 500 mg daily for 3 days has demonstrated 85% clinical cure rate in acute bacterial exacerbations of COPD 3

Oxygen Therapy

For hospitalized patients, administer supplemental oxygen if SpO2 <90%, targeting PaO2 >60 mmHg or SpO2 90-92%. 2, 4

• Prevention of tissue hypoxia takes precedence over concerns about CO2 retention 2
• Arterial blood gases should be monitored in severe exacerbations for PaO2, PaCO2, and pH 2

Indications for Hospitalization

Hospitalize patients with any of the following: 2

• Marked increase in symptom intensity (severe dyspnea)
• Severe underlying COPD
• New physical signs (cyanosis, peripheral edema)
• Failure to respond to initial outpatient management
• Significant comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/liver failure)

Indications for ICU Admission

Transfer to ICU for: 2

• Impending or actual respiratory failure
• Respiratory acidosis with pH <7.26 (consider noninvasive ventilation) 2
• Hemodynamic instability
• Other end-organ dysfunction (shock, renal, liver, or neurological disturbance)

Noninvasive Ventilation

Noninvasive ventilation should be the first mode of ventilation for patients with acute respiratory failure and no absolute contraindications. 1

• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization, and improves survival 1
• Particularly indicated when pH <7.26 with respiratory acidosis 2

Post-Discharge Management

Initiate pulmonary rehabilitation within 3 weeks after hospital discharge—do not start during hospitalization. 1, 2

• Early pulmonary rehabilitation after discharge improves outcomes 1, 2
• Review patient after acute exacerbation to assess treatment response 2

Common Pitfalls to Avoid

• Do not use chest physiotherapy in acute exacerbations—it is not beneficial 2
• Avoid methylxanthines unless patient fails to respond to first-line treatments 2
• Do not delay antibiotics in patients with purulent sputum—bacterial infection is likely present 1
• Over 80% of exacerbations can be managed in the outpatient setting with appropriate pharmacotherapy 1