What medications are used to treat Chronic Obstructive Pulmonary Disease (COPD) exacerbations?

Medications for COPD Exacerbation

For acute COPD exacerbations, initiate treatment immediately with short-acting inhaled beta2-agonists combined with short-acting anticholinergics, systemic corticosteroids (40 mg prednisone daily for 5 days), and antibiotics when purulent sputum is present. 1, 2

Bronchodilator Therapy

Short-acting bronchodilators are the cornerstone of acute exacerbation management:

• Administer short-acting beta2-agonists (SABAs) with or without short-acting anticholinergics (SAMAs) as first-line bronchodilators 1, 2
• For moderate exacerbations, either a beta-agonist or anticholinergic can be given via nebulizer 1
• For severe exacerbations or poor response to monotherapy, combine both SABA and SAMA together 1
• Nebulized bronchodilators should be given upon arrival and at 4-6 hour intervals, but may be used more frequently if needed 1
• Nebulizers are preferred in sicker hospitalized patients as they are easier to use and don't require coordination of 20+ inhalations needed to match nebulizer efficacy 2
• Either metered-dose inhalers (with or without spacer) or nebulizers can be used effectively 2

Important caveat: While combination therapy is recommended for severe exacerbations, one study found no difference in length of hospital stay or spirometric values when ipratropium was added to salbutamol 3. However, current guidelines still recommend combination therapy based on the totality of evidence 1, 2.

Systemic Corticosteroids

Corticosteroids are essential for improving outcomes in COPD exacerbations:

• Administer 40 mg prednisone orally once daily for exactly 5 days 1, 2
• Duration should not exceed 5-7 days 1, 2
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 2
• Systemic glucocorticoids improve lung function, oxygenation, shorten recovery time, and reduce hospitalization duration 1, 2
• Corticosteroids reduce recurrent exacerbations within the first 30 days but provide no benefit beyond this window 2
• Corticosteroids may be less efficacious in patients with lower blood eosinophil levels 2

Antibiotic Therapy

Antibiotics should be given selectively based on clinical criteria:

• Administer antibiotics when patients have increased sputum purulence PLUS either increased dyspnea or increased sputum volume 1, 2
• The three cardinal symptoms indicating antibiotic use are: increased dyspnea, increased sputum volume, and increased sputum purulence 1
• Recommended duration is 5-7 days 1, 2
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 2
• First-line antibiotics include amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid 4
• Alternative treatments include newer cephalosporins, macrolides, and quinolone antibiotics 4
• Antibiotic choice should be based on local bacterial resistance patterns 2
• The most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses 4

Oxygen Therapy

Controlled oxygen delivery is critical to avoid CO2 retention:

• Target oxygen saturation of 90-93% (or PaO2 ≥6.6 kPa) without causing respiratory acidosis 1, 2
• In patients with known COPD aged 50 years or older, initial FiO2 should not exceed 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known 1
• Mandatory arterial blood gas measurement within 1 hour of initiating oxygen to assess for worsening hypercapnia 2

Respiratory Support for Severe Exacerbations

Noninvasive ventilation (NIV) should be first-line for acute respiratory failure:

• NIV should be the first mode of ventilation for patients with acute hypercapnic respiratory failure who have no absolute contraindication 2
• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization duration, and improves survival 1, 2

Medications to Avoid

Intravenous methylxanthines (theophylline) are not recommended due to increased side effect profiles 2

Treatment Algorithm by Severity

• Mild exacerbations: Short-acting bronchodilators only 2
• Moderate exacerbations: Short-acting bronchodilators plus antibiotics and/or oral corticosteroids 2
• Severe exacerbations: All of the above plus hospitalization, controlled oxygen therapy, and consideration for NIV 2

Post-Exacerbation Management

• Initiate maintenance therapy with long-acting bronchodilators (LAMA, LABA/ICS, or LAMA/LABA) before hospital discharge 2
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions 2
• At 8 weeks after an exacerbation, 20% of patients have not recovered to their pre-exacerbation state, highlighting the importance of follow-up 2