What is the management plan for a Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

Management of COPD Exacerbation

Immediately initiate short-acting bronchodilators (with or without anticholinergics), oral prednisone 40 mg daily for exactly 5 days, and add antibiotics only when there is increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2, 3

Initial Bronchodilator Therapy

• Start with short-acting β2-agonists (SABAs) as first-line treatment, with or without short-acting anticholinergics (ipratropium bromide). 1, 2, 3
• For moderate exacerbations, use either agent alone; for severe exacerbations or poor response, combine both agents for superior bronchodilation lasting 4-6 hours. 2, 3
• Deliver via nebulizer (every 4-6 hours) for hospitalized patients or metered-dose inhaler with spacer for outpatients—nebulizers are preferred in sicker patients as they don't require coordination of 20+ inhalations. 2, 3
• Avoid intravenous methylxanthines (theophylline) due to increased side effects without additional benefit. 1, 2

Systemic Corticosteroid Protocol

• Prescribe oral prednisone 40 mg daily for exactly 5 days—this duration is non-inferior to 14 days for preventing re-exacerbation while significantly reducing cumulative steroid exposure. 1, 2, 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). 2, 3
• Do not extend corticosteroid treatment beyond 5-7 days unless there is documented benefit during stable disease—prolonged courses increase adverse effects without additional benefit. 1, 3
• Corticosteroids improve lung function (FEV1), oxygenation, shorten recovery time and hospitalization duration. 1, 2

Antibiotic Therapy Criteria

• Prescribe antibiotics only when there is increased sputum purulence PLUS either increased dyspnea OR increased sputum volume (meeting 2 of 3 criteria). 2, 3
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44%. 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. 1, 2, 3
• Do not prescribe antibiotics empirically without meeting the above criteria—this represents inappropriate use. 3

Oxygen and Respiratory Support

• Target oxygen saturation of 90-93% using controlled oxygen delivery to avoid CO2 retention. 2, 3
• Measure arterial blood gases within 1 hour of initiating oxygen therapy to assess for worsening hypercapnia. 2, 3
• For patients with acute hypercapnic respiratory failure (pH <7.26 and rising PaCO2), initiate noninvasive positive pressure ventilation (NIV) immediately as first-line therapy. 1, 2, 3
• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization, and improves survival. 2

Hospitalization Criteria

Consider hospitalization when any of the following are present: 1, 3

• 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 embolism, left ventricular failure)

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

Classification by Severity

• Mild exacerbations: Treated with short-acting bronchodilators only 1, 2
• Moderate exacerbations: Treated with short-acting bronchodilators plus antibiotics and/or oral corticosteroids 1, 2
• Severe exacerbations: Require hospitalization or emergency room visit; may be associated with acute respiratory failure 1, 2

Discharge Planning and Follow-Up

• Initiate or optimize maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination) before hospital discharge. 1, 2
• Continue nebulized bronchodilators for 24-48 hours until clinical improvement, then transition to metered-dose inhalers 24-48 hours before discharge. 3
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life—starting during hospitalization increases mortality. 2, 3
• Measure FEV1 before discharge to establish new baseline, and check arterial blood gases on room air in patients who presented with respiratory failure. 3
• At 8 weeks after an exacerbation, 20% of patients have not recovered to their pre-exacerbation state, highlighting the importance of follow-up care. 2

Additional Supportive Measures

• Administer diuretics if peripheral edema and elevated jugular venous pressure are present. 3
• Give prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure. 3
• Monitor fluid balance and nutrition status. 2
• Avoid sedatives which worsen respiratory depression. 3
• Do not use chest physiotherapy for acute exacerbations as there is insufficient evidence of benefit. 3

Critical Pitfalls to Avoid

• Never extend corticosteroid courses beyond 5 days without specific indication—this leads to increased adverse effects without additional benefit. 1, 3
• Never prescribe antibiotics without meeting the criteria of increased sputum purulence plus either increased dyspnea or sputum volume. 2, 3
• Never delay hospital evaluation when severity is uncertain—err on the side of caution. 1, 3
• Never use theophylline due to unfavorable side effect profile. 1, 2