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

Treatment of COPD Exacerbation

Treat COPD exacerbations with short-acting bronchodilators (albuterol with or without ipratropium), oral prednisone 40 mg daily for exactly 5 days, and antibiotics when sputum becomes purulent plus either increased dyspnea or sputum volume. 1

Immediate Bronchodilator Therapy

• Administer short-acting β2-agonists (albuterol 2.5-5 mg) combined with short-acting anticholinergics (ipratropium 0.25-0.5 mg) as first-line treatment, providing superior bronchodilation compared to either agent alone 1, 2
• Use nebulizers for hospitalized patients who cannot coordinate the 20+ inhalations required with metered-dose inhalers to match nebulizer efficacy 1
• For mild outpatient exacerbations, short-acting bronchodilators alone may suffice 1
• Avoid intravenous theophylline entirely—it increases side effects without added benefit 1, 3

Systemic Corticosteroid Protocol

• Give oral prednisone 40 mg daily for exactly 5 days—do not extend beyond 5-7 days total as there is no additional benefit and increased risk of side effects 1, 2
• Oral administration equals intravenous effectiveness and should be the default route unless the patient cannot tolerate oral intake 1, 2
• If oral route is impossible, use hydrocortisone 100 mg intravenously 3
• 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 Criteria

• Prescribe antibiotics when there is increased sputum purulence PLUS either increased dyspnea OR increased sputum volume 1, 2
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1
• Treat for 5-7 days with first-line choices: amoxicillin-clavulanate, macrolides (azithromycin), or tetracyclines based on local resistance patterns 1, 2
• Send purulent sputum for culture and obtain blood cultures if pneumonia is suspected 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
• A pH below 7.26 predicts poor prognosis 3

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

Treatment Setting Algorithm

• Mild exacerbations: Treat outpatient with short-acting bronchodilators only 1, 2
• Moderate exacerbations: Treat outpatient with bronchodilators plus antibiotics and/or oral corticosteroids 1, 2
• Severe exacerbations: Hospitalize, particularly with acute respiratory failure, severe dyspnea, use of accessory muscles, cyanosis, peripheral edema, or confusion 1, 2
• More than 80% of exacerbations can be managed outpatient 1, 2

Discharge Planning and Prevention

• Initiate maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination) before hospital discharge 1, 2
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life 1, 2
• 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 with severe COPD and history of exacerbations), or macrolide antibiotics (if frequent bacterial exacerbations) 1, 4

Critical Pitfalls to Avoid

• Never 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 1, 2
• Always differentiate COPD exacerbations from mimics: acute coronary syndrome, heart failure, pulmonary embolism, pneumonia, and pneumothorax 1, 3
• Obtain chest radiography, full blood count, urea, electrolytes, and electrocardiogram as part of urgent investigations 3