What is the management approach for acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

Management of Acute Exacerbation of COPD

For acute COPD exacerbations, prescribe short-acting bronchodilators immediately, add oral prednisone 40 mg daily for exactly 5 days, and reserve antibiotics only for patients with increased sputum purulence plus either increased dyspnea or increased sputum volume. 1

Initial Assessment for Severity

Hospitalize immediately if any of the following are present:

• Loss of alertness or confusion 1, 2
• Severe dyspnea with use of accessory muscles 1, 2
• Cyanosis or significant hypoxemia 1
• Peripheral edema with signs of right heart failure 1
• Failure to respond to initial outpatient treatment 1, 2
• Presence of comorbidities (pneumonia, pneumothorax, pulmonary embolus, left ventricular failure) 1

For hospitalized patients, obtain arterial blood gases, chest radiography, full blood count, urea, electrolytes, and electrocardiogram urgently. 2

Bronchodilator Therapy (First-Line Treatment)

Administer short-acting beta-agonists (salbutamol 2.5-5 mg or terbutaline 5-10 mg) as first-line therapy. 1, 2

For moderate exacerbations, use either a beta-agonist or anticholinergic (ipratropium bromide 0.25-0.5 mg) alone. 1, 2

For severe exacerbations or poor response to monotherapy, combine both beta-agonist and anticholinergic agents. 1, 2

Deliver via nebulizer at 4-6 hourly intervals for hospitalized patients, or metered-dose inhaler with spacer for outpatients. 1

Systemic Corticosteroid Protocol

Prescribe oral prednisone 40 mg daily for exactly 5 days—this duration is non-inferior to 14 days for preventing reexacerbation while significantly reducing cumulative steroid exposure. 1, 2 This represents the strongest evidence-based recommendation from the American College of Physicians and American Thoracic Society. 1

Use oral administration as the default route; it is equally effective to intravenous delivery. 1, 2 Switch to 100 mg hydrocortisone IV only if the patient cannot tolerate oral intake. 1, 2

Discontinue corticosteroids after 5 days—do not extend the course unless there is documented benefit during stable disease. 1 The AAFP guideline acknowledges insufficient evidence to guide duration, but the most recent high-quality evidence strongly supports the 5-day protocol. 3, 1

Antibiotic Therapy (Selective Use)

Prescribe antibiotics only when two or more of the following cardinal symptoms are present: 1, 2, 4

1. Increased breathlessness
2. Increased sputum volume
3. Development of purulent sputum (most important indicator)

This selective approach is recommended by the Infectious Diseases Society of America and American Thoracic Society to reduce unnecessary antibiotic resistance. 1, 4

Treat for 5-7 days with one of the following based on local resistance patterns: 1, 4

• Amoxicillin-clavulanate (first-line for moderate to severe exacerbations)
• Azithromycin 500 mg daily for 3 days
• Tetracycline derivatives
• Ciprofloxacin (when Pseudomonas aeruginosa is a risk factor)

For severe exacerbations requiring mechanical ventilation, antibiotics are strongly indicated regardless of sputum characteristics. 4

Oxygen Therapy and Respiratory Support

Target oxygen saturation of 90-93% using controlled oxygen delivery to avoid CO2 retention. 1, 2

In patients over 50 years with COPD history, do not administer oxygen at FiO2 greater than 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known. 2

Measure arterial blood gases within 60 minutes of initiating oxygen therapy and within 60 minutes of any change in oxygen concentration. 2

For patients with pH <7.26 and rising PaCO2 who fail initial therapy, initiate non-invasive positive pressure ventilation (NIPPV) immediately as first-line ventilatory support. 1, 2 NIPPV improves gas exchange, reduces respiratory work and need for intubation, decreases hospital stay, and improves survival. 2

Additional Therapies

Administer diuretics if peripheral edema and elevated jugular venous pressure are present. 1

Give prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure. 1

Do not use chest physiotherapy for acute exacerbations as there is insufficient evidence of benefit. 1

Consider methylxanthines (aminophylline 0.5 mg/kg per hour by continuous infusion) only if the patient does not respond to bronchodilators and corticosteroids, though these are generally not recommended due to increased side effect profile. 2

Discharge Planning and Follow-Up

Continue nebulized bronchodilators for 24-48 hours until clinical improvement, then transition to metered-dose inhalers or dry powder inhalers 24-48 hours before discharge. 1

Initiate or optimize maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination therapy) before hospital discharge. 1, 2

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

Measure FEV1 before discharge to establish new baseline, and check arterial blood gases on room air in patients who presented with respiratory failure. 1

Critical Pitfalls to Avoid

Do not extend corticosteroid courses beyond 5 days—this leads to increased adverse effects without additional benefit. 1 The older guideline from 1995 and some sources suggest longer durations, but the most recent high-quality evidence from the American College of Physicians definitively supports 5 days. 3, 1

Do not prescribe antibiotics empirically without meeting the criteria of increased sputum purulence plus either increased dyspnea or sputum volume. 1, 4

Avoid sedatives which worsen respiratory depression. 1

Do not delay hospital evaluation when severity is uncertain—err on the side of caution and assess in the Emergency Department. 3, 1

Avoid over-oxygenation—a pH below 7.26 is predictive of poor prognosis and indicates need for immediate ventilatory support. 2