Treatment of Acute Exacerbation of COPD
For acute COPD exacerbations, administer systemic corticosteroids (oral or IV) combined with short-acting bronchodilators (beta-2 agonists and/or anticholinergics), and add antibiotics if the patient has increased sputum purulence along with increased dyspnea or sputum volume. 1
Immediate Bronchodilator Therapy
- Initiate short-acting beta-2 agonists (SABA) as first-line bronchodilator therapy because they produce rapid bronchodilation and improve dyspnea 2, 3
- Add ipratropium (short-acting anticholinergic) when the patient is severely ill or responds inadequately to SABA alone 4
- Deliver bronchodilators via metered-dose inhaler with spacer device rather than nebulizer—both routes are equally effective, but MDI with spacer is more practical 3, 4
- Avoid combining multiple bronchodilators during the acute phase, as adding a second bronchodilator to the first offers minimal additional benefit 2, 3
Important caveat: Ipratropium as monotherapy has not been adequately studied for acute exacerbations and drugs with faster onset (SABA) are preferable as initial therapy 5
Systemic Corticosteroids
- Administer oral or intravenous corticosteroids for 10-14 days to all patients with acute exacerbations 1, 2
- Systemic corticosteroids prevent hospitalization for subsequent exacerbations in the first 30 days following the initial exacerbation (Grade 2B) 1
- The benefits of reducing recurrent exacerbations outweigh short-term risks of hyperglycemia, weight gain, and insomnia 1
- Note that systemic corticosteroids have not been shown to reduce exacerbations beyond the 30-day window 1
Antibiotic Therapy
- Prescribe antibiotics for patients with severe exacerbations, particularly those with increased sputum purulence 2, 4
- Antibiotic use is justified in patients with severe airflow limitation who have febrile tracheobronchitis 4
- Up to 80% of COPD exacerbations have an infectious etiology, and bacterial strain changes have been documented during exacerbations 2
- Newer generation antibiotics may offer better response rates 2
Oxygen Therapy
- Administer supplemental oxygen via Venturi mask to maintain oxygen saturation just above 90%—this approach is both appropriate and safe 2
- Avoid excessive oxygen supplementation that could suppress hypoxic respiratory drive
Supportive Care Considerations
- Obtain baseline chest radiography and arterial blood gas analysis during exacerbation to exclude mimicking conditions (heart failure, pulmonary embolism, pneumothorax, nonpulmonary infections) 2
- Do not use mucolytic agents or chest physiotherapy during acute exacerbations—there is no evidence of benefit 2
- Consider noninvasive positive pressure ventilation for patients with rapid decline in respiratory function and gas exchange, as it may decrease intubation need and in-hospital mortality 2
Post-Exacerbation Management
After stabilizing the acute exacerbation, optimize maintenance therapy to prevent future exacerbations:
- For patients with moderate to severe COPD who experience one or more moderate/severe exacerbations per year despite optimal inhaler therapy, add long-term macrolide therapy (Grade 2A) 1
- Consider the risks of QT prolongation, hearing loss, and bacterial resistance when prescribing macrolides 1
- Ensure patients are on appropriate long-acting bronchodilator maintenance therapy (LAMA/LABA combination preferred) 6