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

Treatment of COPD Exacerbation

Immediately initiate short-acting bronchodilators (salbutamol/albuterol or ipratropium), 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

• 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 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, 2
• Systemic glucocorticoids improve lung function, oxygenation, shorten recovery time, and reduce hospitalization duration 2

Antibiotic Therapy

• Initiate antibiotics when 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 1
• Azithromycin demonstrates 85% clinical cure rate at Day 21-24 for acute bacterial exacerbations of COPD 3
• Treat for 5-7 days only 2
• Common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1

Oxygen Therapy

• Provide supplemental oxygen if SpO2 <90%, targeting PaO2 >60 mmHg or SpO2 ≥90% 1, 2
• In known COPD patients aged 50 years or older, initial FiO2 should not exceed 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are obtained 2
• Prevention of tissue hypoxia takes precedence over CO2 retention concerns 1

Respiratory Support

• Consider non-invasive ventilation (NIV) for patients with respiratory acidosis (pH <7.26) 1
• NIV improves gas exchange, reduces work of breathing, decreases hospitalization duration, and improves survival 2
• Monitor arterial blood gases in severe exacerbations for PaO2, PaCO2, and pH 1

Hospitalization Criteria

Admit to hospital if any of the following are present: 1

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

ICU Admission Criteria

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
• Methylxanthines (aminophylline) should only be considered if the patient is not responding to first-line treatments 1
• Diuretics should only be used if peripheral edema and raised jugular venous pressure are present 1

Post-Discharge Management

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