What is the initial management for a patient with chronic obstructive pulmonary disease (COPD) exacerbation presenting with purulent sputum and cough, considering an increase in albuterol (bronchodilator) therapy?

Management of COPD Exacerbation with Purulent Sputum and Cough

This patient requires triple therapy: increased short-acting bronchodilators (albuterol), systemic corticosteroids, and antibiotics, as the presence of purulent sputum with increased cough represents a moderate exacerbation requiring all three interventions. 1

Immediate Bronchodilator Management

• Increase short-acting inhaled β2-agonists (albuterol) immediately, with or without short-acting anticholinergics (ipratropium), as these are the recommended initial bronchodilators for acute exacerbations 1
• Albuterol can be administered via metered-dose inhaler with spacer or nebulizer at 2.5-5 mg every 4-6 hours, with onset of action within 5 minutes and peak effect at 1 hour 2, 3
• Combining ipratropium with albuterol provides superior relief of dyspnea compared to either agent alone 3
• Ensure proper inhaler technique, as this significantly impacts treatment effectiveness 1, 4

Antibiotic Therapy - Critical for Purulent Sputum

Antibiotics are indicated because this patient meets the classic criteria: increased sputum purulence plus increased cough, which predicts bacterial infection. 1

• The presence of two or more of the following mandates antibiotic therapy: increased breathlessness, increased sputum volume, or development of purulent sputum 1
• First-line antibiotics: amoxicillin or tetracycline for 5-7 days, unless recently used with poor response 1, 4
• Second-line options for more severe cases or inadequate response: amoxicillin-clavulanate, broad-spectrum cephalosporins, newer macrolides (azithromycin), or fluoroquinolones 1, 4
• Antibiotics reduce treatment failure, early relapse, hospitalization duration, and mortality in moderately or severely ill patients 1, 3

Systemic Corticosteroid Therapy

• Prescribe oral corticosteroids (prednisolone 30 mg daily) for 7-14 days to improve lung function, oxygenation, and shorten recovery time 1
• Corticosteroids are particularly beneficial in patients with purulent sputum and should be started concurrently with antibiotics 1, 3
• Oral administration is equally effective to intravenous in most cases 4
• Do not continue corticosteroids long-term after the acute episode unless there is documented benefit in the stable state 1

Classification and Severity Assessment

This represents a moderate exacerbation requiring treatment with short-acting bronchodilators plus antibiotics and oral corticosteroids 1

Key symptoms defining exacerbations include:

• Increased sputum purulence (present in this case) 1
• Increased sputum volume 1
• Increased dyspnea 1
• Increased cough and wheeze (present in this case) 1

Critical Pitfalls to Avoid

• Do not withhold antibiotics when purulent sputum is present - this indicates bacterial infection requiring treatment 1, 4
• Nebulizers driven by compressed air are preferred over oxygen-driven nebulizers if the patient has hypercapnia or respiratory acidosis 1
• Methylxanthines (theophylline/aminophylline) are not recommended due to side effects and lack of clear benefit 1
• Short-course antibiotic therapy (5-7 days) is as effective as longer courses and reduces antimicrobial resistance risk 4

Follow-Up and Monitoring

• Reassess within 48-72 hours to ensure clinical improvement 1
• If no response to initial therapy, consider chest radiograph to exclude pneumonia, pneumothorax, or other complications 1
• Initiate or optimize maintenance long-acting bronchodilator therapy before discharge or once acute symptoms resolve 1
• Address smoking cessation, vaccination status, and exacerbation prevention strategies at follow-up 1

When to Consider Hospitalization

Admit if the patient develops:

• Inadequate response to outpatient management 1
• Severe dyspnea at rest 1
• Confusion or altered mental status 1
• New or worsening hypoxemia requiring supplemental oxygen 4, 5
• Respiratory acidosis on arterial blood gas 1