What is the treatment for chronic obstructive pulmonary disease (COPD) exacerbation?

Treatment of COPD Exacerbation

Start immediately with short-acting β2-agonists (albuterol) combined with short-acting anticholinergics (ipratropium), oral prednisone 40 mg daily for exactly 5 days, and antibiotics if the patient has increased sputum purulence plus either increased dyspnea or increased sputum volume. 1

Bronchodilator Therapy (First-Line Treatment)

Administer short-acting bronchodilators as the cornerstone of acute management:

• Use albuterol (SABA) combined with ipratropium (short-acting anticholinergic) for superior bronchodilation in severe exacerbations 1
• For moderate exacerbations, either agent alone (albuterol 2.5-5 mg or ipratropium 0.25-0.5 mg via nebulizer) may suffice 2
• Metered-dose inhalers with spacers are equally effective as nebulizers, but nebulizers are preferred for hospitalized patients who cannot coordinate the 20+ inhalations needed to match nebulizer efficacy 1
• Avoid intravenous methylxanthines (theophylline) due to increased side effects without added benefit 1, 3

Systemic Corticosteroids (Essential Component)

Give oral prednisone 40 mg daily for exactly 5 days—no longer:

• This regimen improves lung function, oxygenation, shortens recovery time, and reduces hospitalization duration 1, 3
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1
• Do not extend therapy beyond 5-7 days, as there is no additional benefit and increased risk of side effects 1
• Corticosteroids may be less effective in patients with lower blood eosinophil levels, though this should not prevent their use 1, 3

Antibiotic Therapy (When Indicated)

Prescribe antibiotics when the patient has increased sputum purulence PLUS either increased dyspnea OR increased sputum volume:

• This approach reduces short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1, 3
• Treat for 5-7 days with empirical therapy based on local resistance patterns 1, 2
• First-line choices include amoxicillin-clavulanate, macrolides (azithromycin), or tetracyclines 1, 2
• Send purulent sputum for culture if present 2

Oxygen Therapy (For Hospitalized Patients)

Target oxygen saturation of 90-93% using controlled delivery:

• Use Venturi mask at ≤28% FiO2 or nasal cannula at 2 L/min initially in patients over 50 years old with known COPD 1, 2
• Obtain arterial blood gas within 1 hour of initiating oxygen to assess for worsening hypercapnia and CO2 retention 1, 2
• The goal is to achieve PaO2 ≥60 mmHg (6.6 kPa) without causing pH to drop below 7.26 2
• Do not withhold oxygen for fear of CO2 retention—monitor with arterial blood gases and adjust accordingly 1

Respiratory Support (For Severe Exacerbations)

Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with acute hypercapnic respiratory failure who have no absolute contraindications:

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates, shortens hospitalization, and improves survival 1, 3, 2
• Consider invasive mechanical ventilation if NIV fails or if absolute contraindications exist 2

Treatment Setting Based on Severity

Classify exacerbations to determine appropriate treatment location:

• Mild exacerbations: Treat outpatient with short-acting bronchodilators only 1
• Moderate exacerbations: Manage outpatient with addition of antibiotics and/or oral corticosteroids to bronchodilators 1
• Severe exacerbations: Require hospitalization or emergency department visit, particularly with acute respiratory failure 1, 2
• More than 80% of exacerbations can be managed on an outpatient basis 1, 3

Discharge Planning and Prevention

Before hospital discharge, initiate maintenance therapy and schedule follow-up:

• Start long-acting bronchodilators (LAMA, LABA, or combination) as soon as possible before discharge 1, 2
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life 1
• At 8 weeks post-exacerbation, 20% of patients have not recovered to baseline, necessitating close follow-up 1, 3
• For patients with ≥2 exacerbations per year despite optimal bronchodilator therapy, consider adding inhaled corticosteroids (if asthma-COPD overlap or high eosinophils), roflumilast (if chronic bronchitis), or macrolide antibiotics (if frequent bacterial exacerbations) 1

Critical Pitfalls to Avoid

• Do not use roflumilast for acute exacerbations—it is only for prevention in severe COPD with chronic bronchitis and history of exacerbations 1
• Always differentiate COPD exacerbations from mimics: acute coronary syndrome, heart failure, pulmonary embolism, and pneumonia 1, 2
• Ipratropium as a single agent has not been adequately studied for acute COPD exacerbation relief; drugs with faster onset may be preferable as initial therapy 4
• A pH below 7.26 on arterial blood gas is predictive of poor prognosis and requires aggressive management 2