Rescue Therapy for Acute COPD Exacerbations
Short-acting beta-2 agonists (SABAs), with or without short-acting anticholinergics (SAMAs), are the recommended initial rescue therapy agents for acute exacerbations of COPD. 1
Primary Bronchodilator Approach
- Short-acting inhaled beta-2 agonists are the first-line initial bronchodilators for acute treatment of COPD exacerbations 1
- Short-acting anticholinergics can be added to SABAs, though they are not required as monotherapy initially 1
- Both metered-dose inhalers (with or without spacer devices) and nebulizers deliver equivalent FEV1 improvements, though nebulizers may be easier for severely ill patients 1
- For acute exacerbations specifically, short-acting bronchodilators remain the treatment of choice as initial therapy 2
Combination Therapy Considerations
- The combination of ipratropium (SAMA) plus a short-acting beta-agonist can be used, though the FDA label explicitly states that combination therapy has not been shown to be more effective than either drug alone in reversing bronchospasm associated with acute COPD exacerbation 3
- When patients are severely ill or respond inadequately to beta-2 agonists alone, adding an anticholinergic agent is appropriate 4
- The combination of SAMA plus SABA is suggested for preventing moderate exacerbations in stable COPD, but this is distinct from acute rescue therapy 1
Dosing and Administration
- Standard albuterol dosing of 2.5 mg via nebulizer is as effective as 5 mg dosing for acute exacerbations, with no difference in recovery time or hospital length of stay 5
- Bronchodilators should be administered frequently during acute exacerbations 4
- The maximal bronchodilatory response to albuterol improves significantly as the exacerbation resolves (Emax FEV1 increases from 0.64 L during exacerbation to 0.94 L during recovery) 5
Critical Pitfall
- Ipratropium bromide as a single agent has not been adequately studied for acute COPD exacerbations, and drugs with faster onset of action (i.e., SABAs) are preferable as initial therapy 3
- Intravenous methylxanthines (theophylline) are not recommended due to increased side effects and minimal additional benefit when patients receive adequate inhaled bronchodilators 1, 4
Adjunctive Therapy
- Systemic corticosteroids (40 mg prednisone daily for 5 days) should be added to bronchodilators, as they shorten recovery time and improve FEV1 and oxygenation 1
- Antibiotics are indicated when patients have increased sputum purulence, three cardinal symptoms (dyspnea, sputum volume, sputum purulence), or require mechanical ventilation 1