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

COPD Exacerbation Treatment

Immediately initiate short-acting bronchodilators (salbutamol 2.5-5 mg or ipratropium 0.25-0.5 mg via nebulizer or MDI with spacer), controlled oxygen therapy targeting SpO₂ 88-92%, prednisone 30-40 mg orally daily for 5 days, and antibiotics if sputum is purulent—this combination reduces treatment failure by over 50% and shortens recovery time. 1

Initial Assessment and Triage

Evaluate severity by examining:

• Hemodynamic and respiratory system status including presence of cyanosis, peripheral edema, or hemodynamic instability 2
• Arterial blood gases in severe cases to assess PaO₂, PaCO₂, and pH 2
• Comorbidities such as pneumonia, cardiac arrhythmia, heart failure, diabetes, or renal/liver failure 2

Oxygen Therapy

Target PaO₂ ≥60 mmHg (≈50 mmHg minimum) 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 ABG results available 1
• Prevention of tissue hypoxia takes precedence over CO₂ retention concerns 2

Bronchodilator Therapy

Administer immediately upon arrival and continue every 4-6 hours (more frequently if needed): 1

• Salbutamol/albuterol 2.5-5 mg and/or ipratropium bromide 0.25-0.5 mg via MDI with spacer or nebulizer 2, 1
• Either agent is acceptable for moderate exacerbations; combination therapy may provide additional benefit 1
• Consider adding a long-acting bronchodilator if patient not already using one 2

Common pitfall: Methylxanthines (aminophylline) should only be considered if patient fails to respond to first-line bronchodilators 2

Systemic Corticosteroids

Prednisone 30-40 mg orally daily for 5 days improves FEV₁, oxygenation, and reduces treatment failure by over 50%. 2, 1

• Oral route is equally effective as intravenous when patient can tolerate oral administration 2, 1
• 5-7 day course is sufficient; longer durations increase adverse effects without improving outcomes 2

Antibiotic Therapy

Initiate antibiotics when sputum characteristics change (increased purulence and/or increased volume). 2, 1

Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 2

First-line antibiotic options for 5-7 days: 2, 1

• Amoxicillin/ampicillin
• Doxycycline
• Cephalosporins
• Macrolides (azithromycin showed 85% clinical cure rate at Day 21-24 in COPD exacerbations) 3

Non-Invasive Ventilation (NIV)

Consider NIV for patients with 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
• Indicated for respiratory acidosis or impending respiratory failure 2

Hospitalization Criteria

Admit to hospital if: 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
• Other end-organ dysfunction (shock, renal, liver, or neurological disturbance)

Treatments to Avoid

• Chest physiotherapy should not be used in acute exacerbations 2
• Diuretics only if peripheral edema and raised jugular venous pressure present 2

Post-Discharge Management

Initiate pulmonary rehabilitation within 3 weeks after hospital discharge to improve outcomes. 2, 1

• Review patient after acute exacerbation to assess response to treatment 2
• Consider home-based management programs for appropriate patients 2