Management of COPD Exacerbation
Immediate Treatment Protocol
For any patient presenting with a COPD exacerbation, immediately initiate the combination of short-acting bronchodilators, controlled oxygen therapy targeting SpO₂ 88-92%, systemic corticosteroids (prednisone 30-40 mg orally daily for 5 days), and antibiotics if sputum is purulent—this four-pronged approach reduces treatment failure by over 50% and shortens recovery time. 1
Bronchodilator Therapy (First-Line)
- Administer short-acting β-agonists (salbutamol/albuterol 2.5-5 mg) and/or ipratropium bromide (0.25-0.5 mg) via metered-dose inhaler with spacer or nebulizer immediately upon presentation 2, 1
- Continue nebulized bronchodilators every 4-6 hours, with more frequent dosing if needed based on symptom response 1
- Either delivery method (nebulizer or MDI with spacer) is acceptable, though vibrating mesh nebulizers may provide marginally better symptom relief 3
- Consider adding a long-acting bronchodilator if the patient is not already using one 2
Oxygen Therapy (Critical for Preventing Hypoxia)
- Target SpO₂ 88-92% or PaO₂ ≥60 mmHg (≥6.6 kPa) 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 arterial blood gas results are available 1
- Prevention of tissue hypoxia takes precedence over CO₂ retention concerns—do not withhold oxygen due to fear of hypercapnia 2
- Monitor arterial blood gases in severe exacerbations for PaO₂, PaCO₂, and pH 2
Systemic Corticosteroids (Essential Component)
- Prescribe prednisone 30-40 mg orally daily for 5-7 days—this improves FEV₁, oxygenation, and reduces treatment failure by over 50% 2, 1
- Oral corticosteroids are equally effective as intravenous when the patient can tolerate the oral route 1
- Do not extend beyond 7 days—longer durations increase adverse effects without improving outcomes 2
Antibiotic Therapy (When Indicated)
- Initiate antibiotics only when sputum characteristics change (increased purulence and/or increased volume) 2, 1
- First-line choices: amoxicillin, doxycycline, or macrolides for 5-7 days targeting common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 2, 1
- Azithromycin demonstrates 85% clinical cure rate at Day 21-24 for acute bacterial exacerbations of COPD 4
Hospitalization Decision Algorithm
Admit to hospital if any of the following are present:
- Marked increase in symptom intensity (severe dyspnea) 2, 1
- Severe underlying COPD 2
- Onset of new physical signs (cyanosis, peripheral edema) 2
- Failure to respond to initial medical management 2, 1
- Significant comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/liver failure) 2, 1
ICU Admission Criteria
Transfer to ICU if:
- Impending or actual respiratory failure 2
- pH <7.26 with rising PaCO₂ despite supportive treatment and controlled oxygen therapy 1
- Hemodynamic instability 2
- Presence of other end-organ dysfunction (shock, renal, liver, or neurological disturbance) 2
Non-Invasive Ventilation (NIV)
- Consider NIV for patients with respiratory acidosis (pH <7.26) who fail to respond to initial treatment 2, 1
- NIV reduces the number of patients requiring invasive ventilation and shortens hospital stay 1
Critical Pitfalls to Avoid
- Do not use chest physiotherapy in acute exacerbations of COPD—it is not beneficial 2
- Methylxanthines (aminophylline) should only be considered if the patient is not responding to first-line treatments 2
- Diuretics should only be used if there is peripheral edema and raised jugular venous pressure 2
- Do not withhold oxygen therapy due to concerns about CO₂ retention—tissue hypoxia prevention is the priority 2