What is the recommended treatment for a patient with chronic obstructive pulmonary disease (COPD) exacerbation?

COPD Exacerbation Treatment

For a patient with COPD exacerbation, immediately initiate short-acting β2-agonists (with or without short-acting anticholinergics), systemic corticosteroids (prednisone 30-40 mg daily for 5 days), and antibiotics if there is increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2

Initial Bronchodilator Therapy

• Start with short-acting β2-agonists (SABAs) as the primary bronchodilator, with or without short-acting anticholinergics (ipratropium). 1, 2
• Either metered-dose inhalers (MDI) with spacer or nebulizers can be used effectively, though nebulizers are preferred in sicker hospitalized patients because they are easier to use and don't require coordination of 20+ inhalations needed to match nebulizer efficacy. 2
• Administer 2 puffs every 2-4 hours during the acute phase for hospitalized patients. 1
• Do not use intravenous methylxanthines (theophylline) due to increased side effects without added benefit. 1

Systemic Corticosteroid Protocol

• Administer prednisone 30-40 mg orally daily for exactly 5 days. 1, 2
• Duration should not exceed 5-7 days to minimize adverse effects. 2
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake. 1, 2
• Corticosteroids improve lung function (FEV1), oxygenation, shorten recovery time and hospitalization duration. 1
• They reduce recurrent exacerbations within the first 30 days but provide no benefit beyond this window. 1, 2
• Corticosteroids may be less efficacious in patients with lower blood eosinophil levels. 2

Antibiotic Therapy

• Give antibiotics when there is increased sputum purulence PLUS either increased dyspnea OR increased sputum volume. 2
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44%. 2
• Recommended duration is 5-7 days. 2
• First-line choices based on local resistance patterns: 1, 2
  • Amoxicillin/clavulanate
  • Doxycycline
  • Macrolides (azithromycin, clarithromycin)
• For patients who have failed prior antibiotic therapy, consider: 1
  • Amoxicillin/clavulanate
  • Respiratory fluoroquinolones
• The most common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 2

Oxygen Therapy for Hospitalized Patients

• Target oxygen saturation of 90-93% (or PaO2 ≥60 mmHg/8 kPa) using controlled oxygen delivery. 1, 2
• Measure arterial blood gases within 1 hour of initiating oxygen to assess for worsening hypercapnia. 2
• Avoid increasing PaO2 much greater than 60 mmHg as this confers little added benefit and may increase risk of CO2 retention leading to respiratory acidosis. 1

Respiratory Support for Severe Exacerbations

• For patients with acute hypercapnic respiratory failure, initiate noninvasive ventilation (NIV) immediately as first-line therapy. 1, 2
• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization duration, and improves survival. 2
• Indications for ICU admission include: impending or actual respiratory failure, presence of other end-organ dysfunction (shock, renal, liver, or neurological disturbance), and/or hemodynamic instability. 1

Determining Treatment Setting

• More than 80% of exacerbations can be managed outpatient. 2
• Hospitalization criteria include: 1
  • Marked increase in intensity of symptoms (sudden onset of resting dyspnea)
  • Severe underlying COPD
  • Onset of new physical signs (cyanosis, peripheral edema)
  • Failure of initial medical management
  • Significant comorbidities
  • Frequent exacerbations
  • Newly occurring arrhythmias
  • Diagnostic uncertainty
  • Older age
  • Insufficient home support

Exacerbation Classification

• Mild: Treated with short-acting bronchodilators only 1, 2
• Moderate: Treated with short-acting bronchodilators plus antibiotics and/or oral corticosteroids 1, 2
• Severe: Requires hospitalization or emergency room visit; may be associated with acute respiratory failure 1, 2

Discharge Planning and Follow-Up

• Initiate maintenance therapy with long-acting bronchodilators as soon as possible before hospital discharge. 1, 2
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 2
• Starting rehabilitation during hospitalization increases mortality, while post-discharge timing reduces admissions. 2
• At 8 weeks after an exacerbation, 20% of patients have not recovered to their pre-exacerbation state, highlighting the importance of follow-up care. 2
• Appropriate measures for exacerbation prevention should be initiated, including smoking cessation counseling and medication review. 1, 2

Common Pitfalls to Avoid

• Do not use theophylline/methylxanthines due to side effects without proven benefit over standard bronchodilators. 1
• Do not extend corticosteroid duration beyond 5-7 days as there is no additional benefit and increased risk of adverse effects. 2
• Do not give antibiotics empirically to all patients—reserve for those with increased sputum purulence plus either increased dyspnea or sputum volume. 2
• Do not delay NIV in patients with acute hypercapnic respiratory failure—it should be first-line therapy, not a last resort before intubation. 1, 2