What is the treatment for Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

Treatment for COPD Exacerbation

Immediately initiate short-acting β2-agonists (albuterol) combined with short-acting anticholinergics (ipratropium), oral prednisone 40 mg daily for exactly 5 days, and antibiotics if there is increased sputum purulence plus either increased dyspnea or increased sputum volume. 1

Bronchodilator Therapy

Combination bronchodilator therapy is superior to single agents and forms the cornerstone of acute treatment:

• Administer short-acting β2-agonists (albuterol) with short-acting anticholinergics (ipratropium) together for all moderate to severe exacerbations, as this combination provides superior bronchodilation compared to either agent alone 1, 2
• For mild exacerbations, short-acting bronchodilators alone may suffice 1
• Use nebulizers for sicker hospitalized patients who cannot coordinate the 20+ inhalations needed with metered-dose inhalers to match nebulizer efficacy 1, 3
• For patients who can coordinate inhalation, metered-dose inhalers with spacers are equally effective 1, 4
• Avoid intravenous methylxanthines (theophylline) entirely—they increase side effects without added benefit 1, 4

Systemic Corticosteroid Protocol

The corticosteroid regimen is precisely defined and should not be extended:

• Give oral prednisone 40 mg daily for exactly 5 days—no longer than 5-7 days total 1, 3
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1, 3
• Systemic corticosteroids improve lung function, oxygenation, shorten recovery time, reduce hospitalization duration, and reduce recurrent exacerbations within the first 30 days 1, 3
• Corticosteroids may be less effective in patients with lower blood eosinophil levels, though this should not prevent their use 1, 4
• Do not extend therapy beyond 5-7 days—there is no additional benefit and increased risk of side effects 1

Antibiotic Therapy

Antibiotics have dramatic mortality benefits when appropriately indicated:

• Prescribe antibiotics when there is increased sputum purulence PLUS either increased dyspnea OR increased sputum volume 1, 3
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1, 3
• Treat for 5-7 days with empirical therapy based on local resistance patterns 1, 3
• First-line choices include amoxicillin-clavulanate, macrolides (azithromycin), or tetracyclines 1, 3

Oxygen Therapy for Hospitalized Patients

Controlled oxygen delivery prevents CO2 retention while correcting hypoxemia:

• Target oxygen saturation of 90-93% using controlled delivery 1, 3
• Use Venturi mask at ≤28% FiO2 or nasal cannula at 2 L/min initially for patients with known COPD aged 50 years or older 1, 4
• 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

Respiratory Support for Severe Exacerbations

Noninvasive ventilation is first-line therapy for acute hypercapnic respiratory failure:

• Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with acute hypercapnic respiratory failure who have no absolute contraindications 1, 3
• NIV improves gas exchange, reduces work of breathing, decreases intubation rates, shortens hospitalization, and improves survival 1, 3

Treatment Setting Based on Severity

More than 80% of exacerbations can be managed outpatient:

• Mild exacerbations: Treat outpatient with short-acting bronchodilators only 1, 3
• Moderate exacerbations: Treat outpatient with bronchodilators plus antibiotics and/or oral corticosteroids 1, 3
• Severe exacerbations: Require hospitalization or emergency department visit, particularly with acute respiratory failure 1, 3

Discharge Planning and Prevention

Early intervention after discharge prevents readmissions:

• Initiate maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination) as soon as possible before hospital discharge 1, 3
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life 1, 3
• Do not start rehabilitation during hospitalization—this increases mortality; post-discharge timing reduces admissions 3
• At 8 weeks post-exacerbation, 20% of patients have not recovered to baseline, necessitating close follow-up 1, 3
• 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), or macrolide antibiotics (if frequent bacterial exacerbations) 1

Critical Pitfalls to Avoid

Several common errors can worsen outcomes:

• Do not use roflumilast for acute exacerbations—it is only for prevention in severe COPD with chronic bronchitis and history of exacerbations 1
• Always differentiate COPD exacerbations from mimics: acute coronary syndrome, heart failure, pulmonary embolism, and pneumonia 1, 4
• Monitor fluid balance and nutrition status during hospitalization 3