What is Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

COPD exacerbations should be treated with short-acting bronchodilators, oral corticosteroids, and antibiotics if bacterial infection is suspected, with the goal of minimizing the negative impact of the current exacerbation and preventing subsequent events. These flare-ups are characterized by increased breathlessness, cough, sputum production, and sputum purulence beyond normal day-to-day variations. According to the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1, COPD exacerbations are classified as mild, moderate, or severe, with severe exacerbations requiring hospitalization or emergency room visits. The treatment for an exacerbation includes short-acting bronchodilators like albuterol (2-4 puffs every 4-6 hours) or ipratropium (2 puffs every 6 hours), oral corticosteroids such as prednisone (40mg daily for 5 days), and often antibiotics if bacterial infection is suspected (commonly azithromycin 500mg on day 1, then 250mg daily for 4 days, or doxycycline 100mg twice daily for 5-7 days) 1.

Key Points to Consider

• COPD exacerbations are primarily triggered by respiratory infections (viral or bacterial), air pollution, or discontinuation of maintenance medications 1.
• Each exacerbation can permanently reduce lung function, so prevention is crucial through vaccination (influenza and pneumococcal), proper use of maintenance medications, pulmonary rehabilitation, and avoiding triggers like cigarette smoke and air pollutants 1.
• Patients should have an action plan to recognize early symptoms and initiate treatment promptly to prevent severe exacerbations 1.
• Severe exacerbations may require hospitalization for oxygen therapy, nebulized bronchodilators, and possibly non-invasive ventilation 1.

Prevention and Management

• Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 1.
• Systemic corticosteroids improve lung function (FEV1) and oxygenation and shorten recovery time and hospitalization duration 1.
• Antibiotics, when indicated, shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration 1.
• Non-invasive ventilation (NIV) should be the first mode of ventilation used to treat acute respiratory failure 1.

Patient Education and Follow-up

• Patients with COPD susceptible to frequent exacerbations (defined as two or more exacerbations per year) have worse health status and morbidity than patients with less-frequent exacerbations 1.
• After an exacerbation, appropriate measures for exacerbation prevention should be initiated, including pulmonary rehabilitation and home-based management programs 1.

From the Research

COPD Exacerbation Management

• COPD exacerbations can cause significant morbidity and mortality, and effective management is crucial to prevent complications and improve patient outcomes 2.
• Management of COPD exacerbations includes various pharmacologic and non-pharmacologic strategies, such as inhaled bronchodilators, systemic steroids, antibiotics, and oxygen therapy 2, 3.

Pharmacologic Interventions

• Inhaled short-acting bronchodilators, such as ipratropium and albuterol, are beneficial in relieving dyspnea and can be used as the first step in outpatient management 3.
• Oral corticosteroids are likely beneficial, especially for patients with purulent sputum, and can reduce the risk of treatment failure and mortality 3.
• Antibiotics can reduce the risk of treatment failure and mortality in moderately or severely ill patients, and the choice of antibiotic should be guided by local resistance patterns and the patient's recent history of antibiotic use 3, 4.

Non-Pharmacologic Interventions

• Smoking cessation and immunization with pneumococcal vaccine are important non-pharmacologic interventions for managing COPD exacerbations 2.
• Pulmonary rehabilitation, long-term oxygen therapy, and ambulatory oxygen therapy can also improve patient outcomes and reduce hospitalizations 2, 5.

Hospitalized Patients

• Hospitalized patients with COPD exacerbations should receive regular doses of short-acting bronchodilators, continuous supplemental oxygen, antibiotics, and systemic corticosteroids 3.
• Noninvasive positive pressure ventilation or invasive mechanical ventilation is indicated in patients with worsening acidosis or hypoxemia 3.

Treatment Adaptation

• Treatment should be adapted to symptoms and the frequency of exacerbations, with a short-acting beta-2 agonist tried first, then replaced by an inhaled long-acting bronchodilator or possibly tiotropium when its effect is too short-lived 6.
• An inhaled corticosteroid can be added if symptoms persist or exacerbations are frequent, but it can cause pneumonia, candidiasis, dysphonia, and adrenal insufficiency 6.