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

Treatment of COPD Exacerbation

For acute COPD exacerbations, immediately initiate short-acting β2-agonists combined with short-acting anticholinergics, systemic corticosteroids (prednisone 40 mg daily for exactly 5 days), and antibiotics (5-day course) when patients present with increased sputum purulence plus either increased dyspnea or increased sputum volume. 1

Bronchodilator Therapy

Combination short-acting bronchodilators provide superior bronchodilation compared to monotherapy and should be the initial treatment:

• Administer short-acting β2-agonists (SABAs) combined with short-acting anticholinergics (SAMAs) immediately upon presentation, providing effects lasting 4-6 hours during the acute phase 1
• Either metered-dose inhalers with spacer or nebulizers can be used effectively, though nebulizers are preferred in sicker hospitalized patients because they are easier to use and don't require coordination of 20+ inhalations needed to match nebulizer efficacy 1
• Continue regular administration every 4-6 hours as needed during the acute phase 1
• Avoid intravenous methylxanthines (theophylline) due to increased side effects without added benefit 1

Systemic Corticosteroid Protocol

Prednisone 40 mg orally once daily for exactly 5 days is the evidence-based standard:

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1
• The 5-day course is equally effective as 14-day courses but reduces cumulative steroid exposure by over 50% 1
• Systemic corticosteroids improve lung function, oxygenation, shorten recovery time and hospitalization duration 1
• Corticosteroids prevent recurrent exacerbations within the first 30 days but provide no benefit beyond this window 1
• Do not exceed 5-7 days duration 1
• Corticosteroids may be less efficacious in patients with lower blood eosinophil levels 1

Antibiotic Therapy

Prescribe a 5-day course of antibiotics when patients meet specific clinical criteria:

• Indication: Increased sputum purulence PLUS either increased dyspnea OR increased sputum volume 1, 2
• Duration: Exactly 5 days (not the traditional 7-10 days) 2
• First-line choices: 1, 2
  • Amoxicillin-clavulanate
  • Macrolides (azithromycin or clarithromycin)
  • Tetracyclines (doxycycline)
• Selection should be based on local bacterial resistance patterns 1
• Most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
• Avoid fluoroquinolones as first-line agents due to potentially permanent disabling side effects 2
• Antibiotics reduce treatment failure by 53% and short-term mortality by 77% 1

Respiratory Support for Severe Exacerbations

For patients with acute hypercapnic respiratory failure, noninvasive ventilation (NIV) should be the first mode of ventilation:

• Initiate NIV immediately as first-line therapy for patients with acute respiratory failure who have no absolute contraindication 1
• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization duration, and improves survival 1
• Target oxygen saturation of 90-93% using controlled oxygen delivery to avoid CO2 retention 1
• Obtain mandatory arterial blood gas measurement within 1 hour of initiating oxygen to assess for worsening hypercapnia 1

Treatment Setting Stratification

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

• Mild exacerbations: Treat with short-acting bronchodilators only 1
• Moderate exacerbations: Treat with short-acting bronchodilators plus antibiotics and/or oral corticosteroids 1
• Severe exacerbations: Require hospitalization or emergency room visit; may be associated with acute respiratory failure 1

Hospitalization indications include: marked increase in symptom intensity, severe underlying COPD, new physical signs, failure to respond to initial outpatient management, significant comorbidities, frequent exacerbations, new arrhythmias, diagnostic uncertainty, older age, or inability to care for self at home 1

Discharge Planning and Follow-Up

Initiate maintenance therapy and prevention strategies before discharge:

• Start maintenance therapy with long-acting bronchodilators (LAMA monotherapy, ICS/LABA combination, or LAMA/LABA combination) as soon as possible before hospital discharge 1
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life 1
• Do not start rehabilitation during hospitalization as this increases mortality 1
• Schedule follow-up within 3-7 days to assess response 1
• Provide smoking cessation counseling at every visit 1
• Review and correct inhaler technique 1
• At 8 weeks after an exacerbation, 20% of patients have not recovered to their pre-exacerbation state, highlighting the importance of follow-up care 1

Common Pitfalls to Avoid

• Do not use corticosteroids for longer than 5-7 days - no additional benefit and increased risk of adverse effects 1
• Do not prescribe antibiotics without meeting the clinical criteria (increased sputum purulence plus either increased dyspnea or increased sputum volume) 1, 2
• Do not extend antibiotic duration beyond 5 days - equivalent outcomes with shorter courses 2
• Do not use theophylline - increased side effects without added benefit 1
• Do not delay NIV in hypercapnic respiratory failure - reduces intubation rates and mortality 1