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

Management of COPD Exacerbation

Immediately initiate short-acting bronchodilators (salbutamol/albuterol or ipratropium), systemic corticosteroids (prednisone 30-40 mg daily for 5-7 days), and antibiotics if sputum is purulent or increased in volume. 1, 2

Initial Bronchodilator Therapy

• Start with short-acting β-agonists (SABA) via metered-dose inhaler with spacer or nebulizer as the cornerstone of acute treatment. 1, 2
• For moderate exacerbations, use either a β-agonist or anticholinergic via nebulizer. 2
• For severe exacerbations or poor response to monotherapy, combine both SABA and short-acting anticholinergic (SAMA) together. 2
• Administer nebulized bronchodilators upon arrival and at 4-6 hour intervals, with more frequent dosing if needed. 2
• Consider adding a long-acting bronchodilator if the patient is not already using one. 1

Systemic Corticosteroids

• Administer prednisone 40 mg orally daily for exactly 5 days (or 30-40 mg for 5-7 days maximum). 1, 2
• Oral corticosteroids are preferred over intravenous in hospitalized patients. 1
• Do not extend treatment beyond 5-7 days, as longer durations increase adverse effects without improving outcomes. 1
• Systemic glucocorticoids improve lung function, oxygenation, shorten recovery time, and reduce hospitalization duration. 2

Antibiotic Therapy

• Initiate antibiotics if the patient has altered sputum characteristics (purulence and/or increased volume). 1
• Antibiotics are indicated when patients have three cardinal symptoms: increased dyspnea, increased sputum volume, and sputum purulence. 2
• First-line options include amoxicillin/ampicillin, cephalosporins, doxycycline, or macrolides for 5-7 days. 1, 2
• Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1
• Azithromycin demonstrates 85% clinical cure rates at Day 21-24 for acute bacterial exacerbations of COPD. 3

Oxygen Therapy

• Provide supplemental oxygen if SpO2 <90%, targeting PaO2 >60 mmHg or SpO2 ≥90%. 1, 2
• In known COPD patients aged 50+ years, start with FiO2 not exceeding 28% via Venturi mask or 2 L/min via nasal cannula until arterial blood gases are obtained. 2
• Prevention of tissue hypoxia takes precedence over CO2 retention concerns. 1
• Monitor arterial blood gases in severe exacerbations for PaO2, PaCO2, and pH. 1

Non-Invasive Ventilation (NIV)

• Consider NIV for patients with respiratory acidosis (pH <7.26). 1
• NIV improves gas exchange, reduces work of breathing, decreases hospitalization duration, and improves survival in acute respiratory failure. 2

Indications for Hospitalization

Admit patients with any of the following: 1

• Marked increase in dyspnea severity
• Severe underlying COPD
• New physical signs (cyanosis, peripheral edema)
• Failure to respond to initial outpatient management
• Significant comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/liver failure)

Indications for ICU Admission

Transfer to ICU for: 1

• Impending or actual respiratory failure
• Hemodynamic instability
• Other end-organ dysfunction (shock, renal, liver, or neurological disturbance)

Treatments to Avoid or Use Cautiously

• Do not use chest physiotherapy in acute exacerbations. 1
• Only consider methylxanthines (aminophylline) if the patient is not responding to first-line treatments. 1
• Use diuretics only if peripheral edema and raised jugular venous pressure are present. 1

Post-Discharge Management

• Initiate pulmonary rehabilitation within 3 weeks after hospital discharge, not during hospitalization itself. 1
• Review the patient after acute exacerbation to assess treatment response. 1
• Consider home-based management programs for appropriate patients. 1