What are the diagnostic and therapeutic management strategies for Chronic Obstructive Pulmonary Disease (COPD) in acute exacerbation?

Management of COPD Acute Exacerbation

Immediately initiate short-acting β2-agonists (SABAs) with or without short-acting anticholinergics as first-line bronchodilator therapy, administer systemic corticosteroids (40 mg prednisone daily for 5 days), and give antibiotics only when there is increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2

Diagnostic Assessment

Clinical Diagnosis

• COPD exacerbation is a clinical diagnosis based on acute worsening of three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence 1
• Measure respiratory rate (often overlooked but critical for severity assessment) and perform arterial blood gas analysis within 1 hour of presentation, especially if oxygen therapy is initiated 2
• Obtain chest imaging in 94% of cases to exclude pneumonia, pulmonary embolism, pneumothorax, and cardiac causes 3
• Do not rely on spirometry during acute exacerbation—it is performed in only 10% of cases and is not necessary for acute management 3

Severity Classification

• Mild: Treated with SABAs only 1
• Moderate: Requires SABAs plus antibiotics and/or oral corticosteroids 1
• Severe: Requires hospitalization or emergency department visit; may be associated with acute respiratory failure 1, 4

Pharmacologic Management

Bronchodilators (First-Line Therapy)

• Administer short-acting inhaled β2-agonists with or without short-acting anticholinergics immediately 1, 2
• Either metered-dose inhalers (with spacer) or nebulizers are equally effective, though nebulizers are preferred in sicker hospitalized patients because they are easier to use and don't require coordination of 20+ inhalations 2
• Effects last 4-6 hours; require regular administration during acute phase 2
• Do NOT use intravenous methylxanthines (theophylline) due to increased side effect profiles without added benefit 1

Systemic Corticosteroids (Evidence Level A)

• Give 40 mg oral prednisone daily for exactly 5 days—do not exceed 5-7 days duration 1, 2
• Oral prednisolone is equally effective to intravenous administration; use oral route unless patient cannot tolerate oral intake 1, 2
• Corticosteroids improve FEV1, oxygenation, shorten recovery time and hospitalization duration, and reduce recurrent exacerbations within 30 days 1, 2
• Caveat: Corticosteroids may be less efficacious in patients with lower blood eosinophil levels 1

Antibiotics (Evidence Level B)

Antibiotic Indications (give antibiotics ONLY if patient meets one of these criteria):

1. All three cardinal symptoms present (increased dyspnea, sputum volume, AND sputum purulence) 1
2. Two cardinal symptoms present IF increased sputum purulence is one of them 1
3. Requires mechanical ventilation (invasive or noninvasive) 1

Antibiotic Selection and Dosing:

• First-line empirical choices: Amoxicillin-clavulanate, macrolide (azithromycin), or tetracycline based on local resistance patterns 1
• Duration: 5-7 days 1
• Azithromycin dosing for COPD exacerbation: 500 mg once daily for 3 days OR 500 mg on Day 1, then 250 mg daily on Days 2-5 5
• In patients with frequent exacerbations, severe airflow limitation, or requiring mechanical ventilation, obtain sputum cultures to identify resistant pathogens 1
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1

Oxygen Therapy and Respiratory Support

Oxygen Administration

• Target oxygen saturation: 88-92% (or 90-93% per some protocols) using controlled oxygen delivery 1, 2
• Mandatory arterial blood gas measurement within 1 hour of initiating oxygen to assess for CO2 retention and worsening acidosis 1, 2

Noninvasive Ventilation (NIV) (Evidence Level A)

• NIV should be the first mode of ventilation for patients with acute hypercapnic respiratory failure who have no absolute contraindication 1, 2
• NIV has 80-85% success rate and reduces mortality, intubation rates, work of breathing, and hospitalization duration 1
• Invasive mechanical ventilation is indicated only after NIV failure 1
• Patients who fail NIV and require subsequent invasive ventilation have greater morbidity, longer hospital stays, and higher mortality 1

Hospital Discharge and Follow-Up

Discharge Planning

• Initiate maintenance therapy with long-acting bronchodilators before hospital discharge 1, 2
• Schedule early follow-up within 30 days (ideally <30 days) after discharge—this reduces exacerbation-related readmissions and 90-day mortality 1
• Refer to pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life 2
• Critical caveat: Starting rehabilitation during hospitalization increases mortality; only initiate post-discharge 2

Follow-Up Assessment

• At 3-month follow-up, perform spirometry and arterial blood gas analysis—lack of these assessments is associated with rehospitalization and mortality 1
• Review discharge therapy, correct inhaler technique, assess and manage comorbidities 1
• 20% of patients have not recovered to pre-exacerbation state at 8 weeks, highlighting importance of continued monitoring 1, 2

Common Pitfalls to Avoid

1. Do not continue corticosteroids beyond 5-7 days—no additional benefit and increased side effects 1, 2
2. Do not give antibiotics empirically to all patients—only when specific criteria are met (purulent sputum plus other symptoms or mechanical ventilation) 1
3. Do not use methylxanthines—increased side effects without proven benefit 1
4. Do not delay NIV in acute respiratory failure—it is first-line therapy and delays worsen outcomes 1
5. Do not target normal oxygen saturations (>94%)—risk of CO2 retention; target 88-92% 1, 2
6. Do not discharge without arranging early follow-up and pulmonary rehabilitation referral—these reduce readmissions 1, 2