Management of Acute Exacerbation of COPD
For acute COPD exacerbations, immediately initiate short-acting bronchodilators (beta-agonists with or without anticholinergics) and prescribe oral prednisone 40 mg daily for exactly 5 days, adding antibiotics only when there is increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2, 3
Initial Bronchodilator Therapy
Administer short-acting beta-agonists (salbutamol 2.5-5 mg or terbutaline 5-10 mg) as first-line bronchodilator therapy, with or without short-acting anticholinergics (ipratropium bromide 0.25-0.5 mg). 1, 2
For moderate exacerbations, use either a beta-agonist or anticholinergic alone; for severe exacerbations or poor response to monotherapy, combine both agents. 1
Deliver via nebulizer (4-6 hourly intervals) for hospitalized patients or metered-dose inhaler for outpatients, ensuring the patient can use the device effectively. 1, 2
In hospitalized patients with elevated PaCO2 or respiratory acidosis, drive nebulizers with compressed air rather than oxygen to prevent worsening hypercapnia, while continuing supplemental oxygen at 1-2 L/min via nasal prongs during nebulization. 1
Do not use intravenous methylxanthines (theophylline/aminophylline) as they increase adverse effects without proven benefit. 1, 2
Systemic Corticosteroid Protocol
Prescribe oral prednisone 40 mg daily for 5 days—this duration is non-inferior to 14 days for preventing reexacerbation while significantly reducing cumulative steroid exposure. 1, 2, 3
The 5-day regimen reduces mean cumulative prednisone dose from 793 mg to 379 mg without increasing reexacerbation rates (37.2% vs 38.4% at 180 days). 3
Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake (use 100 mg hydrocortisone IV if necessary). 1, 2
Corticosteroids improve FEV1 by 140 mL within 72 hours, reduce treatment failure by over 50% (OR 0.48), and decrease hospital length of stay by 1.22 days. 4
Discontinue corticosteroids after 5 days unless there is documented benefit during stable disease or specific indication for long-term treatment—an exacerbation while on oral corticosteroids does not automatically indicate need for long-term inhaled corticosteroids. 1
Antibiotic Therapy
Prescribe antibiotics only when two or more of the following are present: (1) increased breathlessness, (2) increased sputum volume, (3) development of purulent sputum. 1, 2
Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% when appropriately indicated. 2
Treat for 5-7 days with aminopenicillin plus clavulanic acid, a macrolide (azithromycin 500 mg daily for 3 days), or a tetracycline, based on local resistance patterns. 2, 5
Azithromycin 500 mg daily for 3 days achieves 85% clinical cure rate at day 21-24 in acute exacerbations of chronic bronchitis. 5
Oxygen and Respiratory Support
Target oxygen saturation of 90-93% using controlled oxygen delivery to avoid CO2 retention. 2
Measure arterial blood gases within 1 hour of initiating oxygen therapy to assess for worsening hypercapnia. 2
For patients with pH <7.26 and rising PaCO2 who fail initial therapy, initiate non-invasive positive pressure ventilation (NIPPV) immediately as first-line ventilatory support. 1, 2
NIPPV reduces need for intubation, shortens hospital stay, and improves survival compared to invasive ventilation. 1, 2
Confused patients and those with large volume secretions respond poorly to NIPPV and may require invasive ventilation. 1
Additional Therapies
Administer diuretics if peripheral edema and elevated jugular venous pressure are present. 1
Give prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure. 1
Do not use chest physiotherapy for acute exacerbations as there is insufficient evidence of benefit. 1
Assessment for Hospital Admission
Consider hospitalization when any of the following are present: 1, 6
- Loss of alertness or confusion
- Severe dyspnea with use of accessory muscles
- Cyanosis or significant hypoxemia
- Peripheral edema with signs of right heart failure
- Inability to cope at home or inadequate social support
- Failure to respond to initial outpatient treatment
- Presence of comorbidities (pneumonia, pneumothorax, pulmonary embolus, left ventricular failure)
Follow-Up and Discharge Planning
Continue nebulized bronchodilators for 24-48 hours until clinical improvement, then transition to metered-dose inhalers or dry powder inhalers 24-48 hours before discharge. 1, 6
Initiate or optimize maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination therapy) before hospital discharge. 2
Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life—starting during hospitalization increases mortality. 2
Measure FEV1 before discharge to establish new baseline, and check arterial blood gases on room air in patients who presented with respiratory failure. 6
Arrange follow-up within 48 hours for patients discharged from emergency department, with GP notification of the visit. 1
At follow-up, provide smoking cessation counseling, review medication technique and adherence, and discuss strategies to prevent future exacerbations. 1, 2
Common Pitfalls to Avoid
Avoid prolonged corticosteroid courses beyond 5 days—94.9% of patients receive excessive doses (average 147.5 mg prednisone equivalents daily) when not following guidelines, leading to increased adverse effects without additional benefit. 7
Do not prescribe antibiotics empirically without meeting the criteria of increased sputum purulence plus either increased dyspnea or sputum volume. 1, 2
Do not use ipratropium bromide as monotherapy for acute relief in severe exacerbations—it has slower onset than beta-agonists and is not adequately studied as single agent. 8
Avoid sedatives which worsen respiratory depression. 6
Do not delay hospital evaluation when severity is uncertain—err on the side of caution. 6