COPD Exacerbation Treatment
For acute COPD exacerbations, initiate short-acting bronchodilators (with or without anticholinergics) immediately, prescribe oral prednisone 40 mg daily for exactly 5 days, and add antibiotics only when there is increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2
Initial Bronchodilator Therapy
Administer short-acting beta-agonists (salbutamol 2.5-5 mg) as first-line therapy, with or without short-acting anticholinergics (ipratropium 0.25-0.5 mg), as these are the recommended initial bronchodilators for acute exacerbations. 3, 1, 4
For moderate exacerbations, either agent alone may suffice; for severe exacerbations or poor response to monotherapy, combine both agents together. 4, 2
Deliver via nebulizer at 4-6 hourly intervals for hospitalized patients (easier for sicker patients who cannot coordinate 20+ inhalations), or via metered-dose inhaler for outpatients if they can use the device effectively. 1, 2
Avoid methylxanthines (theophylline) as they are not recommended due to increased side effects without additional benefit. 3, 1
Systemic Corticosteroid Protocol
Prescribe oral prednisone 40 mg daily for exactly 5 days—this duration is non-inferior to 14 days for preventing reexacerbation while significantly reducing cumulative steroid exposure. 1, 5
The 5-day regimen reduces mean cumulative prednisone dose from 793 mg to 379 mg without increasing reexacerbation rates (37.2% vs 38.4%, difference -1.2%). 5
Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake (use 100 mg hydrocortisone IV if necessary). 1, 6
Do not taper the corticosteroid dose and do not extend beyond 5-7 days—tapering is unnecessary and longer courses increase adverse effects without additional clinical benefit. 1, 7, 8
Systemic corticosteroids improve lung function (FEV1), oxygenation, and shorten recovery time and hospitalization duration. 3, 4
Antibiotic Therapy
Prescribe antibiotics only when two or more of the following are present: (1) increased breathlessness, (2) increased sputum volume, (3) development of purulent sputum (Anthonisen criteria). 1, 2
Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% when appropriately indicated. 1
Treat for 5-7 days with aminopenicillin plus clavulanic acid, a macrolide (azithromycin 500 mg daily for 3 days), or a tetracycline, based on local resistance patterns. 1, 4
Do not prescribe antibiotics empirically without meeting the criteria—this avoids unnecessary antibiotic exposure and resistance. 2
Oxygen and Respiratory Support
Target oxygen saturation of 90-93% using controlled oxygen delivery (initial FiO2 not exceeding 28% via Venturi mask or 2 L/min via nasal cannulae in known COPD patients aged 50+ until arterial blood gases are known). 1, 4
Measure arterial blood gases within 1 hour of initiating oxygen therapy to assess for worsening hypercapnia and avoid CO2 retention. 1, 2
For patients with pH <7.26 and rising PaCO2 who fail initial therapy, initiate non-invasive positive pressure ventilation (NIV) immediately as first-line ventilatory support. 3, 2
NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization duration, and improves survival. 3, 4
Exacerbation Severity Classification and Treatment Setting
Mild exacerbations: Treat with short-acting bronchodilators only in the outpatient setting. 3
Moderate exacerbations: Treat with short-acting bronchodilators plus antibiotics and/or oral corticosteroids; more than 80% can be managed outpatient. 3, 1
Severe exacerbations: Require hospitalization or emergency room visit; may be associated with acute respiratory failure. 3, 4
Consider hospitalization when any of the following are present: loss of alertness or confusion, severe dyspnea with accessory muscle use, cyanosis or significant hypoxemia, peripheral edema with right heart failure signs, inability to cope at home, inadequate social support, failure to respond to initial outpatient treatment, or presence of comorbidities (pneumonia, pneumothorax, pulmonary embolus, left ventricular failure). 3, 2
Additional Therapies for Severe Exacerbations
Administer diuretics if peripheral edema and elevated jugular venous pressure are present. 2
Give prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure. 2
Monitor fluid balance and nutrition status during hospitalization. 1
Do not use chest physiotherapy for acute exacerbations as there is insufficient evidence of benefit. 2
Avoid sedatives which worsen respiratory depression. 2
Discharge Planning and Follow-Up
Continue nebulized bronchodilators for 24-48 hours until clinical improvement, then transition to metered-dose inhalers or dry powder inhalers 24-48 hours before discharge. 2
Initiate or optimize maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination therapy) as soon as possible before hospital discharge. 3, 1
Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life—starting during hospitalization increases mortality. 1, 2
Measure FEV1 before discharge to establish new baseline, and check arterial blood gases on room air in patients who presented with respiratory failure. 2
At 8 weeks after an exacerbation, 20% of patients have not recovered to their pre-exacerbation state, highlighting the importance of follow-up care. 1
Common Pitfalls to Avoid
Do not extend corticosteroid courses beyond 5 days in most cases—this increases adverse effects (osteoporosis, hyperglycemia, muscle weakness) without additional benefit. 1, 7, 8
Do not delay hospital evaluation when severity is uncertain—err on the side of caution and assess in the emergency department. 3, 2
Do not prescribe antibiotics without meeting Anthonisen criteria (increased sputum purulence plus either increased dyspnea or sputum volume). 1, 2
Do not use methylxanthines due to unfavorable side effect profiles. 3, 1