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

Management of COPD Exacerbation

Immediately initiate short-acting bronchodilators (salbutamol 2.5-5 mg PLUS ipratropium 500 μg via MDI with spacer or nebulizer), oral prednisone 30-40 mg daily for 5-7 days, and antibiotics if sputum is purulent or increased in volume. 1

Initial Assessment and Risk Stratification

Evaluate three critical parameters to determine treatment setting 1:

• Severity markers requiring hospitalization: Severe dyspnea, failure to respond to initial treatment, new cyanosis or peripheral edema, significant comorbidities (pneumonia, arrhythmia, heart failure), or severe underlying COPD 1
• ICU-level severity: Altered mental status (loss of alertness, tendency to doze off suggesting hypercapnic encephalopathy), paradoxically low respiratory rate indicating respiratory muscle fatigue, impending respiratory failure, or hemodynamic instability 1, 2
• Obtain arterial blood gas in severe cases to assess PaO2, PaCO2, and pH—if pH <7.35 with hypercapnia, this mandates NIV consideration 1, 2

A common pitfall: bradypnea (respiratory rate <12 breaths/minute) with drowsiness is ominous, not reassuring, and signals impending respiratory arrest requiring immediate escalation 2.

Bronchodilator Therapy

Short-acting bronchodilators are the cornerstone and must be started immediately 1:

• Administer salbutamol/albuterol 2.5-5 mg PLUS ipratropium bromide 500 μg via MDI with spacer or nebulizer 1, 2
• Either delivery method (nebulizer or MDI with spacer) is effective; vibrating mesh nebulizers may provide marginally greater symptom relief but no substantial difference in lung function improvement 3
• Add a long-acting bronchodilator if the patient is not already using one 1
• Methylxanthines (aminophylline) should only be considered if inadequate response to first-line treatments, as they provide minimal additional benefit when adequate bronchodilators and corticosteroids are used 1, 4

Systemic Corticosteroids

Oral corticosteroids are preferred over intravenous 1:

• Prednisone 30-40 mg orally daily for 5-7 days is the recommended regimen 1
• Longer durations increase adverse effects without improving outcomes 1
• This accelerates recovery when using standard empirical regimens 4

Antibiotic Therapy

Initiate antibiotics if the patient has altered sputum characteristics—specifically purulence and/or increased volume 1:

• First-line options: amoxicillin/ampicillin, cephalosporins, doxycycline, or macrolides 1
• Common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
• Azithromycin 500 mg daily for 3 days demonstrates 85% clinical cure rate at Day 21-24 for acute bacterial exacerbations, with clinical success rates of 91% for S. pneumoniae, 86% for H. influenzae, and 92% for M. catarrhalis 5
• Antibiotics are particularly justified in patients with severe airflow limitation and febrile tracheobronchitis 4

Oxygen Therapy

Target SpO2 88-92%, never exceeding 92% in COPD patients 2, 6:

• Supplemental oxygen is indicated if saturation <90%, targeting PaO2 >60 mmHg or SpO2 >90% 1
• Prevention of tissue hypoxia takes precedence over CO2 retention concerns 1
• Arterial blood gases remain the standard for assessing gas exchange; understand limitations of surrogates (pulse oximetry, capnography) before relying on them 6

Non-Invasive Ventilation

Consider NIV for patients with respiratory acidosis (pH <7.26 or <7.35 with hypercapnia) 1, 2, 6:

• NIV is standard therapy supported by clinical practice guidelines and improves outcomes 6
• Patients with COPD should be extubated to NIV when mechanically ventilated 6
• Management of auto-PEEP is the priority in mechanically ventilated patients, achieved by reducing airway resistance and decreasing minute ventilation 6

Treatments to Avoid

• Do not use chest physiotherapy in acute exacerbations 1
• Diuretics should only be used if there is peripheral edema AND raised jugular venous pressure 1
• High-flow nasal cannula lacks robust high-level evidence for COPD exacerbation management 6

Post-Discharge Management

Initiate pulmonary rehabilitation within 3 weeks after hospital discharge, not during hospitalization 1:

• This improves outcomes and is strongly recommended by multiple guideline societies 1
• Review after acute exacerbation to assess treatment response 1
• Consider home-based management programs for appropriate patients 1