What is the management for a chronic obstructive pulmonary disease (COPD) exacerbation or lung attack?

Management of COPD Exacerbation (Lung Attack)

For a COPD exacerbation, immediately initiate short-acting bronchodilators (beta-2 agonists with or without anticholinergics), systemic corticosteroids (prednisolone 30-40 mg daily for 5 days), and antibiotics if two or more cardinal symptoms are present (increased dyspnea, increased sputum volume, or purulent sputum), while providing controlled oxygen therapy targeting 88-92% saturation. 1, 2

Initial Assessment and Triage

Severity determines treatment location:

• Mild exacerbations can be managed at home if the patient has adequate support and no concerning features 1
• Severe exacerbations require Emergency Department evaluation for potential hospital admission 1
• Life-threatening episodes warrant direct ICU admission, particularly with loss of alertness or severe respiratory distress 1

Key warning signs requiring hospital assessment: 1

• Loss of alertness or confusion
• Inability to manage at home
• Severe dyspnea at rest
• Cyanosis
• Peripheral edema (new or worsening)
• Hemodynamic instability

Pharmacologic Management

Bronchodilators (First-Line)

Short-acting beta-2 agonists (salbutamol 2.5-5 mg or terbutaline 5-10 mg) with or without short-acting anticholinergics (ipratropium 0.25-0.5 mg) should be administered via nebulizer every 4-6 hours initially. 1, 2

• For moderate exacerbations, either agent alone may suffice 1
• For severe exacerbations or poor response, combine both agents 1
• Nebulizers should be driven by compressed air (not oxygen) if PaCO2 is elevated or respiratory acidosis is present 1
• Oxygen can be continued via nasal prongs at 1-2 L/min during nebulization to prevent desaturation 1
• Avoid intravenous methylxanthines due to increased side effects without proven benefit 1, 3

Systemic Corticosteroids (Essential)

Administer prednisolone 30-40 mg orally daily for 5 days (or hydrocortisone 100 mg IV if oral route unavailable). 1, 2

• Corticosteroids shorten recovery time, improve FEV1 and oxygenation, reduce early relapse and treatment failure, and decrease hospitalization length 1
• Oral prednisolone is equally effective to intravenous administration 1
• Do not extend beyond 5-7 days 1
• May be less effective in patients with lower blood eosinophil levels 1

In community settings, oral corticosteroids should be used selectively: 1

• Patient already on oral corticosteroids
• Previously documented response to corticosteroids
• Airflow obstruction fails to respond to increased bronchodilator dose
• First presentation of airflow obstruction

Antibiotics (When Indicated)

Prescribe antibiotics when two or more of the following cardinal symptoms are present: 1, 2

• Increased dyspnea
• Increased sputum volume
• Development of purulent sputum

Duration should be 5-7 days. 1 Azithromycin has demonstrated clinical cure rates of 85% at Day 21-24 for acute exacerbations of chronic bronchitis 4

Oxygen Therapy (Critical but Controlled)

Target oxygen saturation of 88-92% using controlled oxygen delivery. 2

• Avoid high-concentration oxygen therapy, which increases mortality risk 5
• Oxygen saturation above 92% is considered "inappropriate oxygen therapy" and can worsen respiratory acidosis 5
• High inspired oxygen concentrations worsen ventilation/perfusion mismatching and may induce hypoventilation 6

Respiratory Support

Non-Invasive Ventilation (NIV)

NIV should be the first mode of ventilation for patients with acute respiratory failure (pH <7.26 and rising PaCO2) who fail to respond to initial medical therapy. 1, 2

• NIV reduces intubation rates, hospital length of stay, infectious complications, and improves survival 7
• Most effective when initiated early 1
• Contraindications: Confused patients and those with large volume of secretions respond poorly 1

Invasive Mechanical Ventilation

Consider for patients with pH <7.26 and rising PaCO2 despite NIV and optimal medical therapy 1

Additional Therapies

Diuretics: Indicated only if peripheral edema and elevated jugular venous pressure are present 1

Anticoagulation: Prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure 1

Physiotherapy: Not routinely recommended for acute COPD exacerbations 1

Home Management Protocol

For mild exacerbations managed at home: 1

• Initiate or increase bronchodilators (ensure proper inhaler technique)
• Antibiotics if bacterial infection suspected
• Encourage sputum clearance by coughing
• Increase fluid intake
• Avoid sedatives and hypnotics
• Reassess within 48 hours

Instruct patients on warning signs requiring immediate medical attention: worsening dyspnea, confusion, inability to eat/sleep, or lack of improvement within 48 hours 1

Hospital Management Goals

The four primary objectives are: 1

1. Evaluate severity including life-threatening conditions
2. Identify the cause of exacerbation
3. Provide controlled oxygenation
4. Return patient to best previous condition

Common Pitfalls to Avoid

• Never use high-flow oxygen without monitoring: This can precipitate severe respiratory acidosis and worsen outcomes 1, 5, 6
• Do not rely on ipratropium alone for acute relief: It has not been adequately studied as monotherapy for acute exacerbations 3
• Avoid prolonged corticosteroid courses: No benefit beyond 5-7 days and increases side effect risk 1
• Do not prescribe antibiotics reflexively: Use only when cardinal symptoms indicate bacterial infection 1
• Never delay NIV in appropriate candidates: Early initiation improves outcomes significantly 1, 7

Post-Exacerbation Management

After stabilization, initiate long-acting bronchodilator maintenance therapy before hospital discharge 1. Review and optimize preventive measures to reduce future exacerbation risk 1.