What is the treatment for chronic obstructive pulmonary disease (COPD) exacerbation?

Treatment of COPD Exacerbation

For acute COPD exacerbations, immediately initiate short-acting bronchodilators (albuterol with or without ipratropium), oral prednisone 40 mg daily for exactly 5 days, and antibiotics if the patient has increased sputum purulence plus either increased dyspnea or increased sputum volume. 1

Bronchodilator Therapy

• Administer short-acting β2-agonists (albuterol) with or without short-acting anticholinergics (ipratropium) as first-line treatment for all exacerbations. 1, 2

• For severe exacerbations, combine both SABA and short-acting anticholinergics together—this provides superior bronchodilation compared to either agent alone. 1

• Use either metered-dose inhalers with spacers or nebulizers; both are equally effective, though nebulizers are preferred for sicker hospitalized patients who cannot coordinate the 20+ inhalations needed to match nebulizer efficacy. 1

• Avoid intravenous methylxanthines (theophylline) entirely—they increase side effects without providing additional benefit. 1, 3

Systemic Corticosteroid Protocol

• Give oral prednisone 40 mg daily for exactly 5 days—do not extend beyond 5-7 days total. 1, 2, 3

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake. 1, 2

• Systemic corticosteroids improve lung function, oxygenation, shorten recovery time, and reduce hospitalization duration. 1, 2

• Corticosteroids may be less effective in patients with lower blood eosinophil levels, though this should not prevent their use. 1, 2

Antibiotic Therapy

• Prescribe antibiotics when there is increased sputum purulence PLUS either increased dyspnea OR increased sputum volume. 1, 2, 3

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

• Treat for 5-7 days with empirical therapy based on local resistance patterns. 1, 2

• First-line choices include amoxicillin-clavulanate, macrolides (azithromycin), or tetracyclines. 1, 3

Oxygen Therapy for Hospitalized Patients

• Target oxygen saturation of 90-93% using controlled delivery (Venturi mask at ≤28% FiO2 or nasal cannula at 2 L/min initially). 1, 3

• Obtain arterial blood gas within 1 hour of initiating oxygen to assess for worsening hypercapnia and CO2 retention. 1, 3

• Do not withhold oxygen for fear of CO2 retention—monitor with arterial blood gases and adjust accordingly. 1

Respiratory Support for Severe Exacerbations

• Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with acute hypercapnic respiratory failure who have no absolute contraindications. 1, 2, 3

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates, shortens hospitalization, and improves survival. 1, 2, 3

Treatment Setting Based on Severity

• Mild exacerbations: Treat outpatient with short-acting bronchodilators only. 1, 2

• Moderate exacerbations: Manage outpatient with addition of antibiotics and/or oral corticosteroids to bronchodilators. 1, 2

• Severe exacerbations: Require hospitalization or emergency department visit, particularly with acute respiratory failure. 1, 2

• More than 80% of exacerbations can be managed on an outpatient basis. 1, 2

Discharge Planning and Prevention

• Initiate maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination) as soon as possible before hospital discharge. 1, 2

• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 1

• At 8 weeks post-exacerbation, 20% of patients have not recovered to baseline, necessitating close follow-up. 1, 2

• For patients with ≥2 exacerbations per year despite optimal bronchodilator therapy, consider adding inhaled corticosteroids (if asthma-COPD overlap or high eosinophils), roflumilast (if chronic bronchitis), or macrolide antibiotics (if frequent bacterial exacerbations). 1

Critical Pitfalls to Avoid

• Do not use roflumilast for acute exacerbations—it is only for prevention in severe COPD with chronic bronchitis and history of exacerbations. 1, 4

• Do not extend corticosteroid therapy beyond 5-7 days, as there is no additional benefit and increased risk of side effects. 1

• Always differentiate COPD exacerbations from mimics: acute coronary syndrome, heart failure, pulmonary embolism, and pneumonia. 1, 3

• Ensure proper inhaler technique when prescribing bronchodilators to maximize therapeutic benefit. 2