What is the treatment for acute Chronic Obstructive Pulmonary Disease (COPD) exacerbation in the Emergency Department (ED)?

Treatment of Acute COPD Exacerbation in the Emergency Department

Initiate treatment immediately with short-acting bronchodilators (both beta-agonists and anticholinergics together), systemic corticosteroids (40 mg prednisone daily for 5 days), controlled oxygen therapy targeting SpO2 90-93%, and antibiotics if there is increased sputum purulence plus either increased dyspnea or sputum volume. 1, 2

Initial Assessment and Oxygen Therapy

• Measure arterial blood gases within 60 minutes of starting oxygen therapy to assess for hypercapnia and respiratory acidosis, as pH below 7.26 predicts poor outcomes 3
• Target oxygen saturation of 90-93% using controlled delivery (Venturi mask at ≤28% FiO2 or nasal cannula at 1-2 L/min initially) to avoid CO2 retention 3, 2
• Repeat blood gas measurements if the patient is initially acidotic or hypercapnic, or if clinical status deteriorates 3

Bronchodilator Therapy

Administer both short-acting beta-agonists AND anticholinergics together from the start for severe exacerbations rather than using either agent alone 3, 1, 2

• Nebulized salbutamol 2.5-5 mg (or terbutaline 5-10 mg) PLUS ipratropium bromide 0.25-0.5 mg should be given on arrival and repeated every 4-6 hours 3, 1
• Either metered-dose inhalers with spacers or nebulizers are equally effective, though nebulizers are easier for sicker patients who cannot coordinate 20+ inhalations 1, 2
• Drive nebulizers with compressed air (not oxygen) if PaCO2 is elevated or respiratory acidosis is present, while continuing supplemental oxygen via nasal prongs at 1-2 L/min during nebulization 3
• Continue nebulized bronchodilators for 24-48 hours until clinical improvement, then switch to metered-dose inhalers 3

Critical Caveat on Theophylline

Do NOT use intravenous methylxanthines (aminophylline/theophylline) due to increased side effects without proven benefit 1, 2, 4

Systemic Corticosteroids

Give oral prednisolone 30-40 mg daily for exactly 5 days starting immediately 3, 1, 2

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1, 2
• If oral route is not possible, use hydrocortisone 100 mg IV 3
• Do NOT extend treatment beyond 5-7 days as corticosteroids reduce recurrent exacerbations within 30 days but provide no benefit beyond this window 1
• Corticosteroids may be less effective in patients with lower blood eosinophil levels 1, 2
• Discontinue after the acute episode unless there is a definite indication for long-term treatment 3

Antibiotic Therapy

Give antibiotics when there is increased sputum purulence PLUS either increased dyspnea OR increased sputum volume 1, 2

• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1, 2
• Recommended duration is 5-7 days 1, 2
• First-line choices: amoxicillin or tetracycline (unless previously used with poor response) 3
• Second-line alternatives for severe exacerbations or lack of response: broad-spectrum cephalosporin, newer macrolides (e.g., azithromycin), or amoxicillin/clavulanic acid 3, 5
• Base antibiotic selection on local bacterial resistance patterns; common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 3

Respiratory Support for Severe Cases

Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with acute hypercapnic respiratory failure and respiratory acidosis 1, 2

• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization, and improves survival 1, 2
• Consider ICU admission for very severe, life-threatening episodes 3

Additional Considerations

• Diuretics are indicated only if there is peripheral edema and elevated jugular venous pressure 3
• Prophylactic subcutaneous heparin should be given for patients with acute-on-chronic respiratory failure 3
• Chest physiotherapy is NOT recommended in acute COPD exacerbations 3

Discharge Planning

• Initiate maintenance therapy with long-acting bronchodilators before hospital discharge 1, 2
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce readmissions and improve quality of life (do NOT start during hospitalization as this increases mortality) 1
• Provide smoking cessation counseling 1
• At 8 weeks post-exacerbation, 20% of patients have not recovered to baseline, emphasizing the need for close follow-up 1, 2

Common Pitfalls to Avoid

• Do not use ipratropium as monotherapy—the FDA label warns it has not been adequately studied as a single agent for acute COPD exacerbations 6
• Do not delay blood gas measurement—waiting can miss critical hypercapnia or acidosis 3
• Do not power nebulizers with oxygen in hypercapnic patients—use compressed air 3
• Do not extend corticosteroid treatment beyond 5-7 days without specific indication 3, 1