What is the recommended management for acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

Management of Acute COPD Exacerbation

For acute COPD exacerbations, immediately initiate short-acting bronchodilators (beta-agonists with or without anticholinergics), systemic corticosteroids (prednisolone 30-40 mg daily for 5 days), and antibiotics when there is increased sputum purulence plus either increased dyspnea or sputum volume. 1

Initial Assessment and Oxygen Therapy

• Target oxygen saturation of 88-92% using controlled oxygen delivery to avoid CO2 retention 1, 2
• Obtain arterial blood gas within 1 hour of initiating oxygen therapy to assess for hypercapnia 1
• Oxygen administration through venturi mask is appropriate and safe 3

Bronchodilator Therapy

Short-acting bronchodilators are the cornerstone of acute treatment:

• Use short-acting β2-agonists (salbutamol 2.5-5 mg or terbutaline 5-10 mg) as first-line therapy 4
• Add short-acting anticholinergic (ipratropium bromide 0.25-0.5 mg) for severe exacerbations or poor response to beta-agonist alone 4, 1
• Either metered-dose inhalers (with spacer) or nebulizers are equally effective, though nebulizers are preferred for sicker hospitalized patients who cannot coordinate 20+ inhalations 1
• Administer every 4-6 hours initially, continuing for 24-48 hours until clinical improvement 4
• Do NOT use intravenous methylxanthines (theophylline/aminophylline) due to increased side effects without proven benefit 1, 5

Systemic Corticosteroid Protocol

Corticosteroids are essential and improve lung function, oxygenation, and shorten recovery time:

• Prednisolone 30-40 mg orally daily for exactly 5 days 1, 6
• Oral administration is equally effective to intravenous and should be the default route 4, 1
• If oral route not possible, use hydrocortisone 100 mg IV 4
• Do NOT extend beyond 5-7 days - corticosteroids reduce recurrent exacerbations within 30 days but provide no benefit beyond this window 1
• Discontinue after the acute episode unless there is a separate indication for long-term use 4
• Corticosteroids may be less effective in patients with lower blood eosinophil levels 1

Antibiotic Therapy

Antibiotics reduce short-term mortality by 77% and treatment failure by 53% when appropriately indicated:

• Indications: Increased sputum purulence PLUS either increased dyspnea OR increased sputum volume 1, 3
• Duration: 5-7 days 1
• First-line choices (based on local resistance patterns): 1, 7
  • Aminopenicillin with clavulanic acid (amoxicillin-clavulanate)
  • Macrolide antibiotics
  • Tetracyclines (doxycycline)
  • Trimethoprim-sulfamethoxazole
• For severe exacerbations: Consider augmented penicillins, fluoroquinolones, third-generation cephalosporins, or aminoglycosides 7
• Target common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis 7, 3

Respiratory Support for Severe Exacerbations

For patients with acute hypercapnic respiratory failure (pH <7.26 and rising PaCO2):

• Noninvasive ventilation (NIV) should be first-line therapy 4, 1, 5
• NIV reduces need for intubation, shortens hospitalization, decreases infectious complications, and improves survival 1, 5, 2
• Contraindications to NIV: confusion, large volume of secretions, inability to protect airway 4
• If NIV fails or contraindicated, proceed to invasive mechanical ventilation 4

Therapies NOT Recommended

• Chest physiotherapy: No evidence of benefit in acute exacerbations 4
• Mucolytic agents: No role in acute setting 3
• Intravenous theophylline: Increased side effects without proven benefit 1, 5

Hospitalization Criteria

Admit to hospital for:

• Severe exacerbations with acute respiratory failure 1
• pH <7.26 with rising PaCO2 despite initial treatment 4, 1
• Inadequate response to outpatient management 1
• Note: More than 80% of exacerbations can be managed outpatient 1

Discharge Planning and Follow-Up

Before discharge:

• Initiate or optimize maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination) 1
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce readmissions and improve quality of life 1
• Do NOT start rehabilitation during hospitalization as this increases mortality 1

At follow-up visit (essential within 8 weeks):

• 20% of patients have not recovered to pre-exacerbation state at 8 weeks 1
• Review and optimize maintenance therapy 1
• Provide smoking cessation counseling 1
• Assess for need for aggressive preventive strategies if ≥2 exacerbations per year 1

Maintenance Therapy to Prevent Future Exacerbations

For patients with moderate to severe COPD:

• LAMA monotherapy (tiotropium) reduces exacerbations compared to short-acting agents 4
• ICS/LABA combination reduces exacerbations more than LABA alone (Grade 1C) 4
• LAMA/LABA combination or LAMA monotherapy both effectively prevent exacerbations 4
• Triple therapy (LAMA/LABA/ICS) for high-risk patients with frequent exacerbations and moderate-to-high symptom burden 1
• ICS therapy increases pneumonia risk - carefully weigh risk/benefit 4, 1