What are the guidelines for managing Chronic Obstructive Pulmonary Disease (COPD) exacerbations?

COPD Exacerbation Management Guidelines

Initial Assessment and Monitoring

For patients presenting with COPD exacerbation, immediately obtain arterial blood gases to assess oxygenation and acid-base status, perform chest radiograph to rule out pneumonia or complications, and complete blood count, urea and electrolytes, and ECG within the first 24 hours. 1, 2

• Record initial FEV1 and/or peak flow when possible and start a serial peak flow chart 1, 2
• Send sputum for culture if purulent and consider blood cultures if pneumonia is suspected 2
• Repeat arterial blood gas measurements within 60 minutes of starting oxygen therapy and if clinical situation deteriorates 1, 2

Oxygen Therapy

Target oxygen saturation of 88-92% to avoid respiratory acidosis and carbon dioxide retention. 1, 2, 3

• Initially use controlled oxygen therapy with FiO2 ≤28% via Venturi mask or ≤2 L/min via nasal cannulae until arterial blood gases are known in patients with known COPD aged 50 years or more 2
• Gradually increase oxygen concentration until PaO2 is above 7.5 kPa (50 mmHg) if PaO2 is responding without pH deterioration 1
• Check blood gases within 60 minutes of any change in inspired oxygen concentration 2
• Avoid uncontrolled high-flow oxygen which may worsen hypercapnia 1

Bronchodilator Therapy

Administer nebulized short-acting bronchodilators immediately on arrival and continue at 4-6 hourly intervals. 1, 2

• For moderate exacerbations, use either a beta-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) or an anticholinergic drug (ipratropium bromide 0.25-0.5 mg) 4, 2
• For severe exacerbations or if response to either treatment alone is poor, combine both agents 4, 1, 2
• Ensure nebulizers are driven by compressed air if the patient has hypercapnia and/or respiratory acidosis 1
• Continue nebulized bronchodilators for 24-48 hours or until the patient is improving clinically, then transition to metered dose aerosol or dry powder inhalers 4

Corticosteroid Therapy

Prescribe systemic corticosteroids for all adults with acute COPD exacerbations to reduce clinical failure. 4

• Use oral prednisolone 30-40 mg daily for 5-7 days in outpatients 2
• For hospitalized patients, administer 30-40 mg IV daily for 10-14 days of intravenous methylprednisolone 1
• Oral corticosteroids are preferred over intravenous route in hospitalized patients when oral route is feasible 4
• Discontinue corticosteroids after the acute episode (usually 7-14 days) unless specifically indicated for long-term treatment 4, 1, 2
• Do not continue corticosteroids beyond 14 days unless specifically indicated 1

Antibiotic Therapy

Prescribe antibiotics when patients present with at least two of the following: increased dyspnea, increased sputum volume, and purulent sputum. 4, 2, 5

• Antibiotics reduce the risk of short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 2
• First-line options include amoxicillin or tetracycline unless used with poor response prior to admission 4, 2
• Consider broad-spectrum cephalosporins or respiratory fluoroquinolones for more severe exacerbations 1, 2
• Choice of antibiotic should be based on local resistance patterns, affordability, and patient history 4, 1
• Avoid prolonged courses of antibiotics beyond 7 days 1

Ventilatory Support

Consider non-invasive ventilation (NIV) as the first mode of ventilation for patients with acute or acute-on-chronic respiratory failure, particularly if pH < 7.26 and rising PaCO2 despite standard medical management. 4, 1, 2

• NIV reduces mortality and intubation rates by 80-85% and has been shown to reduce the need for intubation and length of hospital stay 1, 2
• Avoid NIV in patients with confusion or large volume of secretions 1
• Consider invasive mechanical ventilation if NIV fails 2
• Factors encouraging use of invasive ventilation include demonstrable remedial reason for current decline (e.g., radiographic evidence of pneumonia), first episode of respiratory failure, and acceptable quality of life 4

Additional Interventions

Consider intravenous methylxanthines (aminophylline 0.5 mg/kg/hour) by continuous infusion only if patient is not responding to current therapy. 4, 1, 2

• Monitor blood levels daily if methylxanthines are used 1
• There is limited evidence on the effectiveness of theophylline in acute exacerbations 4
• Administer diuretics if there is peripheral edema and raised jugular venous pressure 4, 1, 2
• Consider prophylactic subcutaneous heparin for prevention of thromboembolism in patients with acute-on-chronic respiratory failure 4, 1, 2
• Do not use chest physiotherapy routinely as it is not recommended in acute COPD exacerbations 4, 1

Discharge Planning and Follow-up

Arrange early follow-up within 30 days after discharge to review discharge therapy and make necessary changes. 2

• Ensure adequate support for home care 1
• Provide education on medication use and delivery devices 1
• Plan additional follow-up at 3 months to ensure return to stable state 2
• Consider early pulmonary rehabilitation within 3 weeks after hospital discharge to improve outcomes 4, 2
• Do not initiate pulmonary rehabilitation during hospitalization 4
• Review smoking status, inhaler technique, and maintenance medications 2