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

Management of COPD Exacerbation

Immediate Treatment Protocol

For any patient presenting with a COPD exacerbation, immediately initiate the combination of short-acting bronchodilators, controlled oxygen therapy targeting SpO₂ 88-92%, systemic corticosteroids (prednisone 30-40 mg orally daily for 5 days), and antibiotics if sputum is purulent—this four-pronged approach reduces treatment failure by over 50% and shortens recovery time. 1

Bronchodilator Therapy (First-Line)

• Administer short-acting β-agonists (salbutamol/albuterol 2.5-5 mg) and/or ipratropium bromide (0.25-0.5 mg) immediately via metered-dose inhaler with spacer or nebulizer 2, 1
• Continue bronchodilators every 4-6 hours, with more frequent dosing if needed based on symptom response 1
• If the patient is not already using a long-acting bronchodilator, consider adding one during the acute phase 2

Oxygen Therapy (Critical for Hypoxemic Patients)

• Target PaO₂ ≥60 mmHg (or ≥6.6 kPa) or SpO₂ 88-92% without causing respiratory acidosis (pH <7.26) 2, 1
• Start conservatively with FiO₂ 28% via Venturi mask or 2 L/min via nasal cannula until arterial blood gas results are available 1
• Prevention of tissue hypoxia takes precedence over CO₂ retention concerns 2
• Monitor arterial blood gases in severe exacerbations for PaO₂, PaCO₂, and pH 2

Systemic Corticosteroids (Essential Component)

• Prednisone 30-40 mg orally daily for 5 days is the recommended regimen—this improves FEV₁, oxygenation, and reduces treatment failure 2, 1
• A 5-7 day course is sufficient; longer durations increase adverse effects without improving outcomes 2
• Oral corticosteroids are equally effective as intravenous administration when the patient can tolerate the oral route 1

Antibiotic Therapy (When Indicated)

• Prescribe antibiotics when sputum characteristics change with increased purulence and/or increased volume 2, 1
• First-line options: amoxicillin, doxycycline, or macrolides (azithromycin) for 5-7 days 2, 1
• Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2
• Azithromycin demonstrates 85% clinical cure rate at Day 21-24 for acute bacterial exacerbations of COPD 3

Ventilatory Support Decision-Making

Non-Invasive Ventilation (NIV)

• Consider NIV for patients with respiratory acidosis (pH <7.26) and rising PaCO₂ who fail to respond to supportive treatment and controlled oxygen therapy 2, 1
• NIV reduces the number of patients requiring invasive ventilation and shortens hospital stay 1

Hospitalization Criteria

Admit patients to the hospital if they have any of the following 2, 1:

• Marked increase in symptom intensity (severe dyspnea)
• Severe underlying COPD
• Onset of new physical signs (cyanosis, peripheral edema)
• Failure to respond to initial medical management
• Significant comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/liver failure)

ICU Admission Criteria

Transfer to ICU for 2:

• Impending or actual respiratory failure
• Hemodynamic instability
• Presence of other end-organ dysfunction (shock, renal, liver, or neurological disturbance)

Common Pitfalls to Avoid

• Do not use chest physiotherapy in acute exacerbations of COPD—it is not recommended 2
• Methylxanthines (aminophylline) should only be considered if the patient is not responding to first-line treatments 2
• Diuretics should only be used if there is peripheral edema and raised jugular venous pressure 2
• Avoid over-oxygenation; maintain SpO₂ 88-92% rather than normalizing oxygen saturation 1

Post-Discharge Management

• Initiate pulmonary rehabilitation within 3 weeks after hospital discharge—this improves outcomes and should not be started during hospitalization itself 2, 1
• Review after an acute exacerbation to assess response to treatment 2
• Consider home-based management programs for appropriate patients 2