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

Treatment of COPD Exacerbation

For acute COPD exacerbations, immediately initiate short-acting β2-agonists (albuterol) combined with short-acting anticholinergics (ipratropium), systemic corticosteroids (prednisone 40 mg daily for exactly 5 days), and antibiotics when sputum becomes purulent with increased dyspnea or volume. 1

Immediate Bronchodilator Therapy

• Administer short-acting β2-agonists (e.g., albuterol 2.5-5 mg) with short-acting anticholinergics (e.g., ipratropium 0.25-0.5 mg) together for all moderate-to-severe exacerbations, as this combination provides superior bronchodilation compared to either agent alone. 1, 2

• Use nebulizers for sicker hospitalized patients who cannot coordinate the 20+ inhalations required with metered-dose inhalers to match nebulizer efficacy, though both delivery methods are equally effective when properly used. 1, 2

• Avoid intravenous methylxanthines (theophylline/aminophylline) entirely—they increase side effects without providing additional benefit over inhaled bronchodilators. 1, 3

Systemic Corticosteroid Protocol

• Give oral prednisone 40 mg daily (or prednisolone 30-40 mg) for exactly 5 days—do not extend beyond 5-7 days total, as longer courses provide no additional benefit and increase adverse effects. 1, 2, 3

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake (e.g., severe nausea, altered mental status). 1, 2

• Systemic corticosteroids improve lung function, oxygenation, shorten recovery time, reduce hospitalization duration, and decrease recurrent exacerbations within the first 30 days. 1, 2

• Note that corticosteroids may be less effective in patients with lower blood eosinophil levels, though this should not prevent their use. 1, 2

Antibiotic Therapy Criteria

• Prescribe antibiotics when the patient has increased sputum purulence PLUS either increased dyspnea OR increased sputum volume (the "Anthonisen criteria"). 1, 2, 3

• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% when appropriately indicated. 1, 2

• Treat for 5-7 days with empirical therapy based on local resistance patterns: first-line choices include amoxicillin-clavulanate, macrolides (azithromycin), or tetracyclines. 1, 2, 3

• Send purulent sputum for culture if present, and obtain blood cultures if pneumonia is suspected. 3

Oxygen Therapy for Hospitalized Patients

• Target oxygen saturation of 90-93% (PaO2 ≥60 mmHg or 6.6 kPa) using controlled delivery with Venturi mask at ≤28% FiO2 or nasal cannula at 2 L/min initially. 1, 2, 3

• Obtain arterial blood gas within 60 minutes of initiating oxygen therapy and within 60 minutes of any change in oxygen concentration to assess for worsening hypercapnia and CO2 retention. 1, 2, 3

• A pH below 7.26 is predictive of poor prognosis and signals need for escalation of respiratory support. 3

• Do not withhold oxygen for fear of CO2 retention—monitor with arterial blood gases and adjust accordingly. 1

Respiratory Support for Severe Exacerbations

• Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with acute hypercapnic respiratory failure who have no absolute contraindications. 1, 2, 3

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates, shortens hospitalization duration, and improves survival. 1, 2, 3

• Absolute contraindications to NIV include respiratory arrest, cardiovascular instability, inability to protect airway, excessive secretions, and uncooperative patient. 4

Treatment Setting Classification

• Mild exacerbations: Treat outpatient with short-acting bronchodilators only. 1, 2

• Moderate exacerbations: Treat outpatient with short-acting bronchodilators plus antibiotics and/or oral corticosteroids. 1, 2

• Severe exacerbations: Require hospitalization or emergency department visit, particularly with acute respiratory failure, marked increase in symptom intensity, severe underlying COPD, failure to respond to initial management, significant comorbidities, or insufficient home support. 1, 2, 3

• More than 80% of exacerbations can be managed on an outpatient basis. 1, 2

Discharge Planning and Prevention

• Initiate maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination) as soon as possible before hospital discharge. 1, 2, 3

• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life—starting rehabilitation during hospitalization increases mortality. 1, 2

• At 8 weeks post-exacerbation, 20% of patients have not recovered to baseline, necessitating close follow-up. 1, 2

• 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 and severe COPD), or macrolide antibiotics (if frequent bacterial exacerbations). 1, 5

Critical Pitfalls to Avoid

• Do not use roflumilast for acute exacerbations—it is only for prevention in severe COPD with chronic bronchitis and history of exacerbations, not for acute treatment. 1, 6

• Do not extend corticosteroid therapy beyond 5-7 days, as there is no additional benefit and increased risk of side effects including weight loss, psychiatric events, and infections. 1, 2

• Always differentiate COPD exacerbations from mimics: acute coronary syndrome, heart failure, pulmonary embolism, pneumonia, pneumothorax, lung cancer, and upper airway obstruction. 1, 3

• Obtain chest radiography, electrocardiogram, full blood count, urea, electrolytes, and arterial blood gases as part of urgent investigations to rule out alternative diagnoses. 3