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

Management of COPD Acute Exacerbation

Immediately initiate short-acting bronchodilators combined with oral prednisone 40 mg daily for exactly 5 days, and add antibiotics only when there is increased sputum purulence plus either increased dyspnea or increased sputum volume. 1

Initial Bronchodilator Therapy

• Administer nebulized short-acting beta-agonists (salbutamol 2.5-5 mg or terbutaline 5-10 mg) combined with short-acting anticholinergics (ipratropium bromide 0.25-0.5 mg) immediately upon arrival 1, 2
• For moderate exacerbations, either agent alone may suffice, but for severe exacerbations or poor response to monotherapy, combine both agents 1
• Deliver via nebulizer at 4-6 hourly intervals for hospitalized patients, or via metered-dose inhaler with spacer for outpatients if they can use the device effectively 1, 2
• Drive nebulizers with compressed air (not oxygen) if the patient has elevated PaCO2 or respiratory acidosis, while continuing supplemental oxygen at 1-2 L/min via nasal prongs during nebulization 3

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

• 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
• Discontinue corticosteroids after 5 days unless there is documented benefit during stable disease or specific indication for long-term treatment 1
• Avoid prolonging corticosteroid courses beyond 5 days as this increases adverse effects without additional benefit 1, 4

Antibiotic Therapy Decision Algorithm

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

1. Increased breathlessness
2. Increased sputum volume
3. Development of purulent sputum

• When indicated, treat for 5-7 days with aminopenicillin plus clavulanic acid, a macrolide (azithromycin 500 mg daily for 3 days), or a tetracycline, based on local resistance patterns 1, 4
• Send sputum for culture if purulent and consider blood cultures if pneumonia is suspected 2
• Do not prescribe antibiotics empirically without meeting the above criteria—this avoids unnecessary antibiotic exposure and resistance 1

Oxygen Therapy and Monitoring

• Target oxygen saturation of 88-92% (or 90-93%) using controlled oxygen delivery to avoid CO2 retention 1, 2
• In patients with known COPD aged 50 years or more, do not give FiO2 more than 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gas tensions are known 3, 2
• Measure arterial blood gases within 60 minutes of starting oxygen therapy and within 60 minutes of any change in inspired oxygen concentration 3, 2
• If PaO2 is responding and pH effect is modest, increase inspired oxygen concentration until PaO2 is above 7.5 kPa (approximately 56 mmHg) 3

Respiratory Support for Severe Exacerbations

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

• NIV reduces mortality and intubation rates by 80-85% in patients with acute hypercapnic respiratory failure 2
• Consider invasive mechanical ventilation if NIV fails 2

Assessment for Hospital Admission

Consider hospitalization when any of the following are present: 1

• 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 embolus, left ventricular failure)

Initial Investigations

Urgent investigations should include: 3, 2

• Arterial blood gas tensions noting the inspired oxygen concentration (FiO2)
• Chest radiograph
• Full blood count, urea and electrolytes, ECG within first 24 hours
• Initial FEV1 and/or peak flow with serial peak flow chart started as soon as possible

Additional Therapies

• Administer diuretics if peripheral edema and elevated jugular venous pressure are present 1, 2
• Give prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure 1, 2
• Do not use chest physiotherapy for acute exacerbations as there is insufficient evidence of benefit 1
• Avoid sedatives which worsen respiratory depression 1

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, 4
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life—starting during hospitalization increases mortality 1, 4
• Measure FEV1 before discharge to establish new baseline, and check arterial blood gases on room air in patients who presented with respiratory failure 1
• Arrange early follow-up within 30 days after discharge to review discharge therapy and make necessary changes 2

Common Pitfalls to Avoid

• Do not use intravenous methylxanthines (theophylline) due to increased side effect profiles without added benefit 2, 4
• Avoid humidification as there is no evidence it is necessary 3
• Do not delay hospital evaluation when severity is uncertain—err on the side of caution 1
• A pH below 7.26 is predictive of poor outcome and requires immediate escalation of care 3