What are the guidelines for managing Chronic Obstructive Pulmonary Disease (COPD) exacerbations?

COPD Exacerbation Management

For patients presenting with COPD exacerbation, immediately initiate short-acting bronchodilators (nebulized beta-agonist and/or anticholinergic), controlled oxygen therapy targeting SpO₂ 88-92%, oral corticosteroids (prednisolone 30-40 mg daily for 5 days), and antibiotics if at least two cardinal symptoms are present (increased dyspnea, increased sputum volume, or purulent sputum). 1, 2, 3

Initial Assessment and Investigations

Obtain arterial blood gases immediately to assess oxygenation and acid-base status, noting the inspired oxygen concentration. 4, 1, 2 A pH below 7.26 predicts poor outcomes and signals need for escalation of care. 4, 1

Within the first 24 hours, complete:

• Chest radiograph to exclude pneumonia, pneumothorax, or other complications 1, 2
• Full blood count, urea and electrolytes, and ECG 4, 1, 2
• Initial FEV₁ and/or peak flow with serial monitoring 4, 1, 2
• Sputum culture if purulent; blood cultures if pneumonia suspected 4, 1, 2

Repeat arterial blood gases within 60 minutes of starting oxygen therapy, after any change in inspired oxygen concentration, or if clinical deterioration occurs. 4, 1, 2

Oxygen Therapy

Target SpO₂ of 88-92% (PaO₂ ≥6.6 kPa or ≈50 mmHg) without causing respiratory acidosis (pH <7.26). 1, 2, 3, 5

• Start with controlled oxygen delivery: FiO₂ ≤28% via Venturi mask or ≤2 L/min via nasal cannulae in patients with known COPD aged 50 years or more until arterial blood gases are known. 4, 1, 2, 3
• Check blood gases within 60 minutes of starting oxygen and after any concentration change. 4, 1, 2
• If PaO₂ responds without pH deterioration, gradually increase oxygen concentration until PaO₂ >7.5 kPa. 4, 1

Critical pitfall: Uncontrolled high-flow oxygen worsens hypercapnia and respiratory acidosis in COPD patients. 1

Bronchodilator Therapy

Administer nebulized short-acting bronchodilators immediately upon arrival and continue every 4-6 hours (more frequently if needed). 4, 1, 2, 3, 6

• For moderate exacerbations: Use either salbutamol 2.5-5 mg or ipratropium bromide 0.25-0.5 mg. 1, 3
• For severe exacerbations or poor response to monotherapy: Combine both beta-agonist and anticholinergic agents. 1, 2, 6
• Drive nebulizers with compressed air (not oxygen) if patient has hypercapnia and/or respiratory acidosis. 4, 1 Oxygen can be continued via nasal prongs at 1-2 L/min during nebulization. 4
• Continue nebulized therapy for 24-48 hours until clinical improvement, then transition to metered-dose inhalers or dry powder inhalers. 1

Systemic Corticosteroid Therapy

Prescribe oral prednisolone 30-40 mg daily for 5 days for all patients with COPD exacerbation. 1, 2, 3, 7 This improves lung function, oxygenation, shortens recovery time, and reduces treatment failure by over 50%. 1, 3

• Oral route is equally effective as intravenous when patient can tolerate oral administration. 1, 3
• For hospitalized patients unable to take oral medication, use intravenous methylprednisolone 30-40 mg daily. 1
• Discontinue corticosteroids after 5-7 days (maximum 10-14 days) unless specifically indicated for long-term treatment. 1, 2 Prolonged courses beyond this increase adverse effects without additional benefit. 2

Antibiotic Therapy

Prescribe antibiotics when patients present with at least two of the following cardinal symptoms: increased dyspnea, increased sputum volume, or purulent sputum. 1, 2, 6 Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44%. 2

First-line choices:

• Amoxicillin or doxycycline (tetracycline) for 5-7 days, unless recently used with poor response. 4, 1, 3

Second-line options for severe exacerbations or first-line failure:

• Broad-spectrum cephalosporins, respiratory fluoroquinolones, or newer macrolides (e.g., azithromycin 500 mg daily for 3 days). 4, 1, 8
• Base selection on local resistance patterns and patient's recent antibiotic history. 1, 2, 6

Avoid prolonged courses beyond 7 days. 1

Ventilatory Support

Consider non-invasive ventilation (NIV) as first-line ventilatory support for patients with pH <7.26 and rising PaCO₂ despite standard medical management and controlled oxygen therapy. 1, 2, 3 NIV reduces mortality and intubation rates by 80-85% and shortens hospital stay. 1, 2

Contraindications to NIV:

• Confusion or inability to protect airway 1
• Large volume of secretions 1
• Hemodynamic instability 5

Consider invasive mechanical ventilation if NIV fails. 1, 2 In mechanically ventilated patients, prioritize managing auto-PEEP by reducing airway resistance and decreasing minute ventilation. 5

Additional Interventions

• Administer diuretics if peripheral edema and raised jugular venous pressure are present. 1, 2
• Consider intravenous methylxanthines (theophylline) by continuous infusion only if patient is not responding to current therapy. 1, 2 Monitor blood levels daily due to narrow therapeutic index. 1 This is a third-line option given limited efficacy and potential side effects. 2, 9
• Provide prophylactic subcutaneous heparin for prevention of thromboembolism in patients with acute-on-chronic respiratory failure. 1, 2

Hospitalization Decision

Admit patients to hospital if they have:

• Marked increase in symptom intensity 3
• Severe underlying COPD 3
• New physical signs (cyanosis, peripheral edema, confusion) 4
• Failure to respond to initial medical management 3
• Significant comorbidities 3
• Insufficient home support 2
• Acute respiratory failure (pH <7.26, rising PaCO₂) 1, 2

Discharge Planning and Follow-up

Arrange early follow-up within 30 days after discharge to review discharge therapy and make necessary adjustments. 1, 2

• Initiate pulmonary rehabilitation within 3 weeks after hospital discharge to improve outcomes. 1, 3
• Plan additional follow-up at 3 months to ensure return to stable state. 1, 2
• Ensure adequate support for home care and provide education on medication use and delivery devices. 1
• Review smoking status, inhaler technique, and maintenance medications. 2