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

COPD Exacerbation Treatment

For acute COPD exacerbations, immediately initiate short-acting bronchodilators (beta-agonists with or without anticholinergics), add systemic corticosteroids (prednisone 30-40 mg daily for exactly 5 days), and prescribe antibiotics only when at least two of the following are present: increased dyspnea, increased sputum volume, or purulent sputum. 1, 2

Immediate Bronchodilator Therapy (First-Line)

• Administer short-acting beta-2 agonists (SABAs) with or without short-acting anticholinergics as the cornerstone of acute treatment. 1, 2
• For moderate exacerbations: either agent alone is acceptable 2
• For severe exacerbations: combine both agents for superior bronchodilation lasting 4-6 hours 2
• Delivery method: Either metered-dose inhalers (with or without spacer) or nebulizers are equally effective, though nebulizers are preferred for sicker hospitalized patients who cannot coordinate 20+ inhalations 1, 2
• Dosing: Salbutamol 2.5-5 mg and/or ipratropium 0.25-0.5 mg, repeated at 4-6 hour intervals 2
• Avoid intravenous methylxanthines (theophylline) due to increased side effects without added benefit. 1

Systemic Corticosteroid Protocol

• Give oral prednisone 30-40 mg daily for exactly 5 days—do not exceed 5-7 days duration. 1, 2
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1, 2
• Corticosteroids improve lung function, oxygenation, shorten recovery time and hospitalization duration 1
• Benefits include reducing recurrent exacerbations within the first 30 days, but provide no benefit beyond this window 1
• Corticosteroids may be less effective in patients with lower blood eosinophil levels 1

Exception for Community Management

• In the outpatient setting, oral corticosteroids should only be used if: the patient is already on oral corticosteroids, there is previously documented response to oral corticosteroids, airflow obstruction fails to respond to increased bronchodilator dose, or this is the first presentation of airflow obstruction 3

Antibiotic Therapy (Selective Use)

• Prescribe antibiotics ONLY when at least TWO of the following criteria are met: increased dyspnea, increased sputum volume, or development of purulent sputum. 1, 2
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% when appropriately indicated 1
• Duration: 5-7 days 1, 2
• First-line options: aminopenicillin with clavulanic acid, macrolide, tetracycline, or amoxicillin 1, 2
• Second-line: broad-spectrum cephalosporins or newer macrolides 2
• Base antibiotic choice on local bacterial resistance patterns 1

Oxygen Therapy (For Hospitalized Patients)

• Target oxygen saturation of 88-92% (NOT 90-93% as in general populations) using controlled oxygen delivery to avoid CO2 retention. 2
• Start with FiO2 ≤28% via Venturi mask or ≤2 L/min via nasal cannula until arterial blood gas results are available 2
• Mandatory arterial blood gas measurement within 60 minutes of initiating oxygen therapy to assess for worsening hypercapnia. 1, 2
• Target PaO2 ≥60 mmHg (8 kPa) without causing pH <7.26 2
• Recheck ABG within 60 minutes of any oxygen adjustment 2

Respiratory Support for Severe Exacerbations

• Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with acute hypercapnic respiratory failure (pH <7.35), persistent hypoxemia despite supplemental oxygen, or severe dyspnea with respiratory muscle fatigue. 1, 2
• NIV reduces mortality and intubation rates by 80-85%, improves gas exchange, reduces work of breathing, and shortens hospitalization duration 1, 2
• NIV should be used for patients with acute respiratory failure who have no absolute contraindication 1

Treatment Setting Algorithm

• More than 80% of exacerbations can be managed on an outpatient basis. 1
• Mild exacerbations: short-acting bronchodilators only 1
• Moderate exacerbations: short-acting bronchodilators plus antibiotics and/or oral corticosteroids 1
• Severe exacerbations: require hospitalization or emergency room visit, particularly with acute respiratory failure 1

Indicators for Hospitalization

• Use of accessory respiratory muscles 2
• Paradoxical chest wall movements 2
• Cyanosis 2
• New or worsening peripheral edema 2
• Hemodynamic instability 2
• Inability to speak in full sentences 2
• pH <7.26 predicts poor prognosis 2

Post-Exacerbation Management

• Initiate maintenance therapy with long-acting bronchodilators (LAMA monotherapy, LAMA/LABA combination, or ICS/LABA combination) as soon as possible before hospital discharge. 1
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life—do NOT start during hospitalization as this increases mortality. 1
• Follow-up visit provides opportunity for smoking cessation counseling, medication review, and planning for future exacerbation prevention 3, 1
• 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
• Patients with frequent exacerbations (≥2 per year) have worse health status and require more aggressive preventive strategies 1

Common Pitfalls to Avoid

• Do not continue corticosteroids beyond 5-7 days unless specifically indicated—there is no benefit and increased risk of side effects. 1, 2
• Do not prescribe antibiotics empirically without meeting the two-symptom criteria—this promotes resistance without benefit. 1, 2
• Do not target normal oxygen saturations (94-98%)—this can worsen hypercapnia in COPD patients; target 88-92%. 2
• Do not use nebulizers routinely in general practice unless the patient cannot use their inhaler device effectively 3
• Do not start pulmonary rehabilitation during hospitalization—wait until 3 weeks post-discharge 1