What are the treatment guidelines for a COPD (Chronic Obstructive Pulmonary Disease) exacerbation flare-up?

COPD Exacerbation Treatment Guidelines

For acute COPD exacerbations, immediately initiate short-acting bronchodilators (beta2-agonists with or without anticholinergics), systemic corticosteroids (prednisolone 30-40 mg daily for 5-7 days), and antibiotics when indicated by purulent sputum or severe symptoms. 1, 2

Initial Assessment and Monitoring

Upon presentation, obtain the following immediately:

• Arterial blood gas analysis noting the inspired oxygen concentration (FiO2) 3, 1
• Chest radiograph to exclude pneumonia, pneumothorax, or other complications 3
• Complete blood count, electrolytes, and ECG within the first 24 hours 3, 2
• Initial FEV1 and/or peak flow with serial monitoring 3, 2
• Sputum culture if purulent, and blood cultures if pneumonia suspected 3

Oxygen Therapy

Target oxygen saturation of 88-92% to prevent respiratory acidosis while maintaining adequate oxygenation. 2

• In patients with known COPD aged ≥50 years, do not exceed 28% FiO2 via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known 3, 1
• Aim for PaO2 ≥6.6 kPa (≥50 mmHg) without causing pH to fall below 7.26 3, 1
• Recheck blood gases within 60 minutes of starting oxygen or changing FiO2 3, 1
• If PaO2 responds without pH deterioration, gradually increase oxygen until PaO2 >7.5 kPa 3, 2

Critical pitfall: Uncontrolled high-flow oxygen may worsen hypercapnia and respiratory acidosis 2

Bronchodilator Therapy

Moderate Exacerbations

• Nebulized beta-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) OR anticholinergic (ipratropium 0.25-0.5 mg) 3, 1
• Administer every 4-6 hours, more frequently if needed 3, 1

Severe Exacerbations

• Combine both SABA and SAMA (salbutamol plus ipratropium) 3, 1, 2
• For patients with hypercapnia/respiratory acidosis, drive nebulizers with compressed air, not oxygen 3, 2
• Oxygen can be continued at 1-2 L/min via nasal prongs during nebulization 3

Systemic Corticosteroids

Prednisolone 30-40 mg daily for 5-7 days is the evidence-based regimen. 3, 1

• Improves lung function (FEV1), oxygenation, and shortens recovery time and hospitalization duration 3, 1
• Do not exceed 5-7 days duration unless specifically indicated 1, 2
• For hospitalized patients, may use IV methylprednisolone 30-40 mg daily 2

Critical pitfall: Prolonged courses beyond 7-14 days increase adverse effects without additional benefit 3, 2

Antibiotic Therapy

Prescribe antibiotics when patients have purulent sputum or three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence. 1

Duration and Selection

• 5-7 days duration is recommended 1, 2
• First-line: Amoxicillin or tetracycline (unless recently used with poor response) 3, 1
• Second-line: Broad-spectrum cephalosporin or newer macrolides for severe exacerbations or treatment failure 3, 2
• Base selection on local resistance patterns and recent antibiotic history 2, 4

Critical pitfall: Avoid prolonged courses beyond 7 days 2

Noninvasive Ventilation (NIV)

NIV should be the first-line ventilatory support for acute respiratory failure with persistent respiratory acidosis (pH <7.26) despite standard medical management. 3, 2

• Reduces need for intubation, decreases hospitalization duration, and improves survival 1, 2
• Contraindications: Confusion, large volume of secretions, hemodynamic instability 2

Additional Interventions for Severe Cases

Methylxanthines

• Consider aminophylline 0.5 mg/kg/hour continuous infusion only if inadequate response to standard therapy 2
• Monitor blood levels daily due to narrow therapeutic index 2
• Generally not recommended as first-line due to side effects 3

Other Measures

• Diuretics if peripheral edema and elevated jugular venous pressure present 2
• Consider prophylactic subcutaneous heparin for thromboembolism prevention 2

Treatment Algorithm

For ALL exacerbations:

1. Start short-acting bronchodilators immediately 1
2. Add systemic corticosteroids (prednisolone 30-40 mg × 5-7 days) 1
3. Add antibiotics if purulent sputum or severe symptoms (5-7 days) 1
4. Provide controlled oxygen therapy targeting SpO2 88-92% 2

For severe/hospitalized exacerbations:

1. All of the above PLUS
2. Consider NIV if pH <7.26 despite treatment 2
3. Consider aminophylline if inadequate response 2
4. Ensure DVT prophylaxis 2

Interventions NOT Recommended

• Chest physiotherapy: Not beneficial in acute exacerbations 3, 2
• Mucolytic agents: No role in acute setting 5
• Routine humidification: No evidence of benefit 3

Discharge Planning

• Initiate or optimize long-acting bronchodilators (LAMA/LABA) before discharge 3
• Arrange follow-up within 4-6 weeks 2
• Provide education on inhaler technique and exacerbation prevention 2