Management of COPD Exacerbation
Initiate immediate treatment with nebulized short-acting bronchodilators, controlled oxygen therapy targeting SpO2 88-92%, oral corticosteroids 30-40 mg daily for 5-7 days, and antibiotics if the patient has purulent sputum or at least two cardinal symptoms (increased dyspnea, increased sputum volume, or sputum purulence). 1, 2, 3
Initial Assessment and Investigations
Upon presentation, obtain arterial blood gases immediately to assess PaO2, PaCO2, and pH, noting the inspired oxygen concentration. 1, 2 Complete a chest radiograph urgently to exclude pneumonia, pneumothorax, or other complications. 1, 2 Within the first 24 hours, obtain full blood count, urea and electrolytes, and ECG. 1, 2 Record baseline FEV1 and/or peak flow when feasible and start serial monitoring. 1, 2 Send sputum for culture if frankly purulent, and obtain blood cultures if pneumonia is suspected. 1, 2
Critical signs indicating severe exacerbation include: pyrexia, purulent sputum, audible wheeze, tachypnea, use of accessory muscles, peripheral edema, cyanosis, and confusion. 1 A pH below 7.26 predicts poor outcomes and warrants intensive monitoring. 1
Oxygen Therapy
Target oxygen saturation of 88-92% to prevent tissue hypoxia while avoiding worsening hypercapnia and respiratory acidosis. 2, 3, 4 In patients with known COPD aged 50 years or older, initially limit oxygen to FiO2 ≤28% via Venturi mask or ≤2 L/min via nasal cannulae until arterial blood gases are known. 1, 2, 4
Check blood gases within 60 minutes of starting oxygen and within 60 minutes of any change in inspired oxygen concentration. 1, 2, 4 If PaO2 responds without significant pH deterioration, gradually increase inspired oxygen until PaO2 exceeds 7.5 kPa (approximately 60 mmHg). 1, 2 If pH falls secondary to rising PaCO2, consider noninvasive ventilation rather than further oxygen escalation. 1
Bronchodilator Therapy
Administer nebulized short-acting bronchodilators immediately upon arrival and continue at 4-6 hourly intervals. 1, 2, 4 For moderate exacerbations, use either a beta-agonist (albuterol/salbutamol) or anticholinergic (ipratropium); for severe exacerbations or inadequate response to monotherapy, combine both agents. 2, 3, 5
Critical caveat: Drive nebulizers with compressed air (not oxygen) if the patient has hypercapnia and/or respiratory acidosis. 1, 2 Provide supplemental oxygen at 1-2 L/min via nasal prongs during nebulization to prevent desaturation. 1 Continue nebulized therapy for 24-48 hours or until clinical improvement, then transition to metered-dose inhalers or dry powder inhalers. 2
Corticosteroid Therapy
Prescribe oral prednisolone 30-40 mg daily for 5-7 days in all patients with COPD exacerbation. 1, 2, 3, 4 This duration is sufficient and longer courses increase adverse effects without improving outcomes. 3 For hospitalized patients, oral corticosteroids are preferred over intravenous when the oral route is feasible. 1, 3 If intravenous administration is necessary, use methylprednisolone 30-40 mg IV daily. 2
Discontinue corticosteroids after 7-14 days unless specifically indicated for long-term treatment. 2, 4 Do not routinely continue systemic corticosteroids beyond the acute episode. 4 The evidence strongly supports short-course therapy to reduce clinical failure, improve lung function, and shorten recovery time. 1, 3
Antibiotic Therapy
Prescribe antibiotics when patients present with at least two of the following cardinal symptoms: increased dyspnea, increased sputum volume, and purulent sputum. 1, 2, 3, 4 Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44%. 4
First-line antibiotics: Amoxicillin or tetracycline unless recently used with poor response. 1, 2, 4 Second-line options: Broad-spectrum cephalosporins, newer macrolides (azithromycin, clarithromycin), or respiratory fluoroquinolones for more severe exacerbations or lack of response to first-line agents. 1, 2, 3 Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 3
Avoid prolonged antibiotic courses beyond 7 days. 2 Base antibiotic selection on local resistance patterns, patient risk factors, and recent antibiotic history. 2, 3
Noninvasive Ventilation (NIV)
Consider NIV as the first mode of ventilation for patients with acute or acute-on-chronic respiratory failure, particularly when pH <7.26 despite standard medical management. 1, 2, 3, 4 NIV reduces mortality and intubation rates by 80-85% in patients with acute hypercapnic respiratory failure. 4 It also decreases length of hospital stay. 2
Contraindications to NIV: Confusion, large volume of secretions, hemodynamic instability, or inability to protect airway. 2 If NIV fails or is contraindicated, proceed to invasive mechanical ventilation. 3, 4
Additional Interventions
Diuretics: Administer if peripheral edema and raised jugular venous pressure are present, indicating fluid overload. 2, 4
Methylxanthines (theophylline/aminophylline): Consider intravenous administration by continuous infusion only if the patient is not responding to nebulized bronchodilators and standard therapy. 2, 4 Monitor blood levels daily due to narrow therapeutic index. 2 However, evidence for benefit is limited and side effects are common. 4
Thromboembolism prophylaxis: Administer prophylactic subcutaneous heparin in patients with acute-on-chronic respiratory failure, as pulmonary emboli may be underrecognized in severe COPD. 1, 2, 4
Hospitalization Criteria
Admit patients with: Marked increase in symptom intensity (severe dyspnea), severe underlying COPD, new physical signs (cyanosis, peripheral edema), failure to respond to initial outpatient management, significant comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes, renal or liver failure), or insufficient home support. 3, 4
ICU admission indications: Impending or actual respiratory failure, hemodynamic instability, or other end-organ dysfunction (shock, renal, hepatic, or neurological disturbance). 3
Discharge Planning and Follow-up
Arrange early follow-up within 30 days after discharge to review discharge therapy, assess response to treatment, verify inhaler technique, and make necessary medication adjustments. 2, 4 Schedule additional follow-up at 3 months to ensure return to stable state. 2, 4
Initiate pulmonary rehabilitation within 3 weeks after hospital discharge to improve functional capacity and reduce future exacerbation risk. 1, 2, 3, 4 Do not initiate pulmonary rehabilitation during hospitalization itself, as evidence supports early post-discharge rather than inpatient initiation. 1, 3
Ensure adequate home support, provide education on medication use and delivery devices, review smoking status, and develop strategies to prevent future exacerbations. 4