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

COPD Exacerbation Treatment

For acute COPD exacerbations, immediately initiate short-acting bronchodilators (with or without anticholinergics), oral prednisone 40 mg daily for exactly 5 days, and antibiotics only when there is increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2

Initial Bronchodilator Therapy

• Administer short-acting beta2-agonists (SABA) such as salbutamol 2.5-5 mg, with or without short-acting anticholinergics (SAMA) such as ipratropium bromide 0.25-0.5 mg, as first-line treatment. 3, 1, 4, 2

• For mild exacerbations, use SABA alone; for moderate to severe exacerbations or poor response to monotherapy, combine both SABA and SAMA together for superior bronchodilation. 1, 4, 2

• Deliver via nebulizer for hospitalized patients (every 4-6 hours initially, more frequently if needed) or metered-dose inhaler with spacer for outpatients, ensuring proper technique. 1, 4, 2

• Avoid methylxanthines (theophylline) due to increased side effects without added clinical benefit. 3, 1

Systemic Corticosteroid Protocol

• Prescribe oral prednisone 40 mg once daily for exactly 5 days—this duration is non-inferior to 14 days for preventing reexacerbation while significantly reducing cumulative steroid exposure. 1, 2, 5

• The REDUCE trial demonstrated that 5-day treatment was non-inferior to 14-day treatment (hazard ratio 0.95,90% CI 0.70-1.29) with reexacerbation rates of 37.2% versus 38.4%, while reducing mean cumulative prednisone dose from 793 mg to 379 mg. 5

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake (use 100 mg hydrocortisone IV if necessary). 1, 2, 6

• Discontinue corticosteroids after 5 days without tapering—tapering is unnecessary for short courses and provides no additional benefit. 2, 7

• Systemic corticosteroids improve lung function (FEV1), oxygenation, shorten recovery time, and reduce hospitalization duration. 3, 1, 4

Antibiotic Therapy

• Prescribe antibiotics for 5-7 days only when patients have increased sputum purulence PLUS either increased dyspnea OR increased sputum volume (meeting at least 2 of 3 cardinal symptoms with purulence as one). 1, 4, 2

• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% when appropriately indicated. 1

• First-line options include amoxicillin with clavulanic acid, macrolides (azithromycin 500 mg daily for 3 days), or tetracyclines, based on local resistance patterns. 1, 4, 2

• The most common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and respiratory viruses. 1

Oxygen and Respiratory Support

• Target oxygen saturation of 88-92% (or 90-93%) using controlled oxygen delivery to avoid CO2 retention. 1, 4, 2

• For 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 obtained. 4

• Measure arterial blood gases within 1 hour of initiating oxygen therapy to assess for worsening hypercapnia. 1, 2

• For patients with acute hypercapnic respiratory failure (pH <7.26 and rising PaCO2), initiate noninvasive ventilation (NIV) immediately as first-line therapy—NIV improves gas exchange, reduces work of breathing, decreases intubation rates, shortens hospitalization, and improves survival. 3, 1, 4, 2

Classification and Treatment Setting

• Mild exacerbations: Treated with short-acting bronchodilators only. 3, 1

• Moderate exacerbations: Treated with short-acting bronchodilators plus antibiotics and/or oral corticosteroids. 3, 1

• Severe exacerbations: Require hospitalization or emergency room visit; may be associated with acute respiratory failure. 3, 1

• More than 80% of exacerbations can be managed on an outpatient basis. 1

Hospitalization Criteria

Consider hospitalization when any of the following are present: 2

• Loss of alertness or confusion
• Severe dyspnea with use of accessory muscles
• Cyanosis or significant hypoxemia
• Peripheral edema with signs of right heart failure
• Inability to cope at home or inadequate social support
• Failure to respond to initial outpatient treatment
• Presence of comorbidities (pneumonia, pneumothorax, pulmonary embolism, left ventricular failure)

Discharge Planning and Follow-Up

• Initiate or optimize maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination therapy) before hospital discharge. 3, 1

• Continue nebulized bronchodilators for 24-48 hours until clinical improvement, then transition to metered-dose inhalers 24-48 hours before discharge. 2

• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life—starting during hospitalization increases mortality. 1, 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. 3, 1

• Measure FEV1 before discharge to establish new baseline, and check arterial blood gases on room air in patients who presented with respiratory failure. 2

Common Pitfalls to Avoid

• Do not extend corticosteroid treatment beyond 5 days—longer courses increase adverse effects without additional benefit. 2, 5

• Do not prescribe antibiotics empirically without meeting the criteria of increased sputum purulence plus either increased dyspnea or sputum volume. 2

• Avoid sedatives which worsen respiratory depression. 2

• Do not use chest physiotherapy for acute exacerbations as there is insufficient evidence of benefit. 2

• Do not delay hospital evaluation when severity is uncertain—err on the side of caution. 2