What is the management of Chronic Obstructive Pulmonary Disease (COPD) exacerbation in the emergency department?

COPD Exacerbation Management in the Emergency Department

Immediately administer controlled oxygen therapy targeting SpO2 88-92%, nebulized bronchodilators (beta-agonist and anticholinergic for severe cases), oral prednisolone 30-40 mg daily for 5-7 days, and antibiotics if at least two cardinal symptoms are present (increased dyspnea, increased sputum volume, purulent sputum). 1, 2

Initial Assessment and Diagnostic Workup

Upon ED arrival, obtain the following immediately:

• Arterial blood gas analysis to assess hypoxemia, hypercapnia, and respiratory acidosis 1, 2
• Chest radiograph to exclude pneumonia, pneumothorax, or pulmonary edema 1
• Complete blood count, electrolytes, and ECG 1, 2
• FEV1 and/or peak flow when feasible 1
• Sputum culture if purulent; blood cultures if pneumonia suspected 1

Assess for life-threatening features requiring ICU admission: altered mental status, severe hypoxemia (PaO2 <50 mmHg), respiratory acidosis (pH <7.35), or hemodynamic instability. 2

Oxygen Therapy

Target SpO2 of 88-92% to correct hypoxemia while preventing CO2 retention. 1, 2, 3

• Initially use controlled oxygen delivery via Venturi mask (FiO2 ≤28%) or nasal cannula (≤2 L/min) until arterial blood gases are available 1
• Recheck arterial blood gases within 60 minutes of starting oxygen and after any change in inspired oxygen concentration 1

Critical pitfall: High-flow oxygen commonly causes hypercapnia in COPD patients. Studies show that FiO2 >0.28 is inappropriately used in 54 patients pre-hospital and 35 patients in ED among those who develop hypercapnia. 4 This practice increases risk of respiratory failure requiring noninvasive ventilation or ICU admission. 4

Bronchodilator Therapy

Administer nebulized bronchodilators immediately upon arrival and continue at 4-6 hour intervals. 1, 2

• For moderate exacerbations: Use either a beta-agonist OR anticholinergic 1
• For severe exacerbations: Use BOTH beta-agonist AND anticholinergic combination therapy 1, 2

Short-acting bronchodilators remain first-line treatment during acute exacerbations. 2

Systemic Corticosteroid Therapy

Administer oral prednisolone 30-40 mg daily for 5-7 days for all COPD exacerbations requiring medical attention. 5, 1, 2

• Oral and intravenous routes are equally effective; use oral unless patient cannot tolerate oral intake 5
• Discontinue after 5-7 days unless specifically indicated for long-term treatment 1, 2
• Systemic corticosteroids improve lung function, oxygenation, shorten recovery time, and reduce hospitalization duration 2

Critical pitfall: Avoid prolonged courses beyond 7-14 days due to increased adverse effects without additional benefit. 2 Do not routinely continue corticosteroids long-term after an exacerbation. 1

Antibiotic Therapy

Prescribe antibiotics when patients present with at least two of three cardinal symptoms: increased dyspnea, increased sputum volume, and purulent sputum. 5, 1, 2

Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44%. 1, 2

Antibiotic selection:

• First-line options: Amoxicillin or tetracycline 1, 2
• Second-line options: Broad-spectrum cephalosporins or newer macrolides 1, 2
• Tailor selection based on local resistance patterns and patient risk factors 2

Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 6

Noninvasive Ventilation (NIV)

Initiate NIV as first-line ventilatory support for patients with acute or acute-on-chronic respiratory failure. 5, 1, 2, 3

Specific indications for NIV:

• Persistent hypoxemia despite supplemental oxygen 1, 2
• Respiratory acidosis (pH <7.35) 1, 2
• Severe dyspnea with signs of respiratory muscle fatigue 1, 2

NIV reduces mortality and intubation rates by 80-85% in appropriate patients. 1, 2 Consider invasive mechanical ventilation if NIV fails. 1

Additional Measures

• Consider diuretics if peripheral edema and raised jugular venous pressure are present 1
• Consider intravenous methylxanthines if response to nebulized bronchodilators is poor, though evidence is limited and side effects are common 1, 6
• Administer prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure 1

Disposition and Follow-up

Arrange follow-up within 30 days after discharge to review discharge therapy and make necessary adjustments. 1, 2

Schedule additional follow-up at 3 months to ensure return to stable state. 1, 2

Initiate early pulmonary rehabilitation within 3 weeks after hospital discharge to improve exercise capacity, reduce healthcare costs, and decrease future exacerbation rates. 2