What are the treatment guidelines for managing chronic obstructive pulmonary disease (COPD) and asthma exacerbations in the inpatient setting?

Management of COPD and Asthma Exacerbations in the Inpatient Setting

For hospitalized patients with COPD or asthma exacerbations, immediately initiate short-acting bronchodilators (salbutamol/albuterol and ipratropium), systemic corticosteroids (prednisone 30-40 mg daily for 5-7 days), supplemental oxygen targeting SpO2 ≥90%, and antibiotics if sputum is purulent or increased in volume. 1, 2

Initial Assessment and Diagnostic Workup

Immediate Evaluation

• Obtain arterial blood gas (ABG) to assess PaO2, PaCO2, and pH—critical for determining severity and need for ventilatory support 3, 1
• Order chest radiograph to exclude pneumonia, pneumothorax, or other complications 2
• Complete blood count, electrolytes, and ECG should be obtained on admission 2
• Assess for respiratory acidosis (pH <7.26) as this indicates need for non-invasive ventilation 1

Clinical Indicators Requiring Hospitalization

• Marked increase in dyspnea intensity or severe underlying disease 1
• New physical signs: cyanosis, peripheral edema, altered mental status 1
• Failure to respond to outpatient management 1
• Significant comorbidities: pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/liver failure 1

ICU Admission Criteria

• Impending or actual respiratory failure 1
• Hemodynamic instability or shock 1
• Other end-organ dysfunction (renal, hepatic, neurological) 1

Bronchodilator Therapy

First-Line Treatment

• Administer short-acting β-agonists (salbutamol/albuterol) AND ipratropium via metered-dose inhaler with spacer or nebulizer 3, 1, 2
• Dosing: 2 puffs every 2-4 hours initially, can be given more frequently if needed 3, 2
• For severe exacerbations, use both agents together rather than monotherapy 2
• Nebulized bronchodilators should be given upon arrival and at 4-6 hour intervals 2

Additional Bronchodilator Considerations

• Consider adding long-acting β-agonist if patient not already using one 1
• Avoid theophylline/aminophylline unless patient is not responding to first-line treatments—it is a weak bronchodilator with narrow therapeutic index and significant side effects 1, 4

Systemic Corticosteroid Therapy

Dosing and Duration

• Prednisone 30-40 mg orally daily for 5-7 days (NOT 10-14 days as older guidelines suggested) 3, 1, 2
• If patient cannot tolerate oral intake, give equivalent dose intravenously 3, 1
• Oral route is preferred over IV when patient can tolerate—equally effective with lower cost 3
• Duration should NOT exceed 5-7 days to minimize side effects 2

Mechanism and Benefits

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

Antibiotic Therapy

Indications for Antibiotics

• Initiate antibiotics if patient has purulent sputum and/or increased sputum volume 3, 1, 2
• Three cardinal symptoms support antibiotic use: increased dyspnea, increased sputum volume, and increased sputum purulence 2

Antibiotic Selection

• First-line options: Amoxicillin/clavulanate, respiratory fluoroquinolones (levofloxacin, moxifloxacin) 3, 1
• Alternative first-line: Amoxicillin, tetracycline, cephalosporins, doxycycline, macrolides 1, 2
• If Pseudomonas or Enterobacteriaceae suspected, use combination therapy 3
• Duration: 5-7 days 2

Oxygen Therapy

Target and Delivery

• Target PaO2 >60 mmHg or SpO2 ≥90% 1, 2
• Initiate supplemental oxygen if saturation <90% 3, 1
• Use nasal cannula or Venturi masks as primary delivery devices 3
• In known COPD patients ≥50 years, start with FiO2 ≤28% via Venturi mask or 2 L/min via nasal cannula until ABG results available 2

Critical Principle

• Prevention of tissue hypoxia takes precedence over CO2 retention concerns 3, 1
• If CO2 retention with acidemia occurs, consider non-invasive ventilation rather than withholding oxygen 3

Ventilatory Support

Non-Invasive Ventilation (NIV)

• Strongly recommended for patients with acute hypercapnic respiratory failure and respiratory acidosis (pH <7.26) 3, 1
• NIV improves gas exchange, reduces work of breathing, decreases hospitalization duration, and improves survival 2
• Requires same level of supervision as invasive mechanical ventilation 3

Contraindications to NIV

• Impaired consciousness or confusion 3
• Hemodynamic instability 1
• Inability to protect airway 3

Invasive Mechanical Ventilation

• Reserved for patients who fail NIV or have contraindications to NIV 3
• Use obstructive lung strategy with permissive hypercapnia 5

Treatments to AVOID

Ineffective or Harmful Interventions

• Do NOT use chest physiotherapy in acute exacerbations 1
• Do NOT initiate pulmonary rehabilitation during hospitalization—it increases mortality 3
• Avoid diuretics unless there is peripheral edema AND raised jugular venous pressure 1
• Methylxanthines should only be considered as last resort 1

Discharge Planning and Follow-Up

Post-Discharge Management

• Initiate pulmonary rehabilitation within 3 weeks after hospital discharge (NOT during hospitalization) 3, 1
• This reduces hospital readmissions and improves quality of life 3
• Review patient after acute exacerbation to assess treatment response 1
• Reassess oxygen requirements—discontinue if patient no longer meets criteria 3

Key Pitfalls to Avoid

• Do not extend corticosteroid duration beyond 5-7 days—older guidelines recommended 10-14 days but this increases side effects without added benefit 3, 2
• Do not use IV corticosteroids routinely—oral route is equally effective and preferred 3
• Do not withhold oxygen due to CO2 retention fears—hypoxia is more dangerous than hypercapnia 3, 1
• Do not start pulmonary rehabilitation in hospital—wait until 3 weeks post-discharge 3
• Monitor for acidemia when giving oxygen; if pH drops, escalate to NIV rather than reducing oxygen 3

Special Considerations for Asthma vs COPD

While the core treatment principles overlap, note that:

• Inhaled corticosteroids are first-line controllers for asthma but provide less benefit in COPD 6
• In COPD, ICS should not be used as monotherapy and are primarily added to reduce exacerbations in severe disease 7
• Consider adding magnesium, ketamine, or epinephrine for severe asthma exacerbations not responding to initial therapy 5