What is the recommended treatment for a patient experiencing a Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

Management of COPD Exacerbation

All patients experiencing a COPD exacerbation should receive short-acting bronchodilators (beta-agonists with or without anticholinergics), systemic corticosteroids (prednisone 30-40 mg daily for 5 days), and antibiotics if sputum is purulent or increased in volume. 1, 2

Initial Bronchodilator Therapy

Short-acting bronchodilators are the cornerstone of acute treatment and should be initiated immediately. 3, 1

• For moderate exacerbations: Start with either a short-acting beta2-agonist (SABA) OR short-acting anticholinergic (SAMA) via nebulizer or metered-dose inhaler with spacer 1, 2

• For severe exacerbations or poor response: Administer BOTH SABA and SAMA together 1, 2

• Dosing frequency: Give nebulized bronchodilators upon arrival, then every 4-6 hours, but may be used more frequently if needed 2

• If the patient is not already on a long-acting bronchodilator, consider adding one during the acute phase 1

Systemic Corticosteroids

Corticosteroids improve lung function, oxygenation, shorten recovery time, and reduce hospitalization duration. 2

• Dose: Prednisone 30-40 mg orally daily 1, 2

• Duration: 5-7 days maximum—longer courses provide no additional benefit 1, 2

• Route: Oral corticosteroids are preferred over intravenous in hospitalized patients 3

The evidence strongly supports short-course corticosteroids, with the 2017 ERS/ATS guideline 3 and 2021 AAFP guideline 3 both emphasizing that 5-7 days is sufficient and longer durations increase adverse effects without improving outcomes.

Antibiotic Therapy

Antibiotics should be initiated when patients have altered sputum characteristics—specifically purulence and/or increased volume. 1, 2

• Classic indication: Presence of all three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence 2

• First-line options: Amoxicillin/ampicillin, cephalosporins, doxycycline, or macrolides 1

• Duration: 5-7 days 2

• Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 3

The FDA label for azithromycin demonstrates clinical cure rates of 85% at day 21-24 for acute bacterial exacerbations of chronic bronchitis 4, supporting macrolides as a reasonable first-line option.

Oxygen Therapy

Supplemental oxygen should be administered if SpO2 <90%, with a target PaO2 >60 mmHg or SpO2 ≥90%. 1, 2

• Critical principle: Prevention of tissue hypoxia takes precedence over concerns about CO2 retention 1

• Initial delivery in known COPD patients ≥50 years: Start with FiO2 ≤28% via Venturi mask or 2 L/min via nasal cannula until arterial blood gases are obtained 2

• Monitoring: Arterial blood gases should be checked in severe exacerbations to assess PaO2, PaCO2, and pH 1

Indications for Hospitalization

Hospitalize patients with any of the following: 1

• Marked increase in dyspnea intensity (severe dyspnea) 1
• Onset of new physical signs: cyanosis or peripheral edema 1
• Failure to respond to initial outpatient management 1
• Severe underlying COPD 1
• Significant comorbidities: pneumonia, cardiac arrhythmia, heart failure, diabetes, renal or liver failure 1

Indications for ICU Admission

Transfer to ICU for: 1

• Impending or actual respiratory failure 1
• Respiratory acidosis with pH <7.26—consider noninvasive ventilation (NIV) 1
• Hemodynamic instability 1
• Presence of other end-organ dysfunction (shock, renal, liver, or neurological disturbance) 1

NIV improves gas exchange, reduces work of breathing, decreases hospitalization duration, and improves survival in patients with acute respiratory failure 2.

Treatments to AVOID or Use Cautiously

• Chest physiotherapy: NOT recommended in acute COPD exacerbations 1

• Methylxanthines (aminophylline): Only consider if patient is not responding to first-line bronchodilators 1—they provide little additional benefit when adequate bronchodilators and corticosteroids are used 5

• Ipratropium as monotherapy: Has not been adequately studied as a single agent for acute COPD exacerbation relief; drugs with faster onset may be preferable initially 6

• Diuretics: Only use if there is peripheral edema AND raised jugular venous pressure 1

Post-Discharge Management

Initiate pulmonary rehabilitation within 3 weeks after hospital discharge. 3, 1

• Do NOT start pulmonary rehabilitation during the hospitalization itself 3

• Review patients after an acute exacerbation to assess treatment response 1

• Consider home-based management programs for appropriate patients 3

The evidence from the 2017 ERS/ATS guideline 3 specifically recommends against initiating rehabilitation during hospitalization but strongly supports early initiation (within 3 weeks) after discharge to improve outcomes.