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

Treatment of COPD Exacerbation

Treat COPD exacerbations with short-acting bronchodilators (albuterol with or without ipratropium), oral prednisone 40 mg daily for exactly 5 days, and antibiotics for 5-7 days when sputum purulence increases along with either worsening dyspnea or increased sputum volume. 1, 2, 3

Immediate Bronchodilator Therapy

• Administer short-acting β2-agonists (SABA) such as albuterol combined with short-acting anticholinergics (SAMA) such as ipratropium as first-line treatment. 1, 2, 3
• For severe exacerbations, use both SABA and SAMA together for superior bronchodilation compared to either agent alone. 1, 3
• Deliver via metered-dose inhaler with spacer or nebulizer—both are equally effective, though nebulizers are preferred for sicker hospitalized patients who cannot coordinate the 20+ inhalations needed to match nebulizer efficacy. 1, 2, 3
• Dose every 4-6 hours during the acute phase as needed. 2
• Avoid intravenous methylxanthines (theophylline) due to increased side effects without added benefit. 1, 2, 3

Systemic Corticosteroid Protocol

• Give oral prednisone 40 mg once daily for exactly 5 days—no longer than 5-7 days total. 1, 2, 3
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake. 1, 2, 3, 4
• This 5-day regimen is non-inferior to 14-day courses but reduces cumulative steroid exposure by over 50%. 2, 5
• Systemic corticosteroids improve lung function, oxygenation, shorten recovery time, reduce hospitalization duration, and decrease treatment failure by over half (OR 0.48). 1, 2, 3, 6
• Corticosteroids may be less effective in patients with lower blood eosinophil levels, though this should not prevent their use. 1, 2, 3

Critical Pitfall: Do not extend corticosteroid therapy beyond 5-7 days—there is no additional benefit and increased risk of hyperglycemia and other adverse effects. 1, 3, 6

Antibiotic Therapy

• Prescribe antibiotics when there is increased sputum purulence PLUS either increased dyspnea OR increased sputum volume (Anthonisen criteria). 1, 2, 3
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44%. 1, 2, 3
• Treat for 5-7 days with empirical therapy based on local resistance patterns. 1, 2, 3
• First-line choices include amoxicillin-clavulanate, macrolides (azithromycin), or tetracyclines. 2, 3
• Target common organisms: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses. 2

Treatment Setting and Severity Classification

• Mild exacerbations: Treat outpatient with short-acting bronchodilators only. 2, 3
• Moderate exacerbations: Treat outpatient with bronchodilators plus antibiotics and/or oral corticosteroids. 2, 3
• Severe exacerbations: Require hospitalization or emergency department visit, particularly with acute respiratory failure. 1, 2, 3
• More than 80% of exacerbations can be managed on an outpatient basis. 1, 2, 3

Indications for hospitalization: Marked increase in symptom intensity, severe underlying COPD, new physical signs (e.g., cyanosis, peripheral edema), 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. 2

Oxygen Therapy for Hospitalized Patients

• Target oxygen saturation of 90-93% (or 88-92% in some protocols) using controlled delivery. 1, 2, 3
• Start with Venturi mask at ≤28% FiO2 or nasal cannula at 2 L/min initially in patients aged 50+ with known COPD. 1
• Obtain arterial blood gas within 1 hour of initiating oxygen to assess for worsening hypercapnia and CO2 retention. 1, 2, 3

Critical Pitfall: Do not withhold oxygen for fear of CO2 retention—monitor with arterial blood gases and adjust accordingly. 3

Respiratory Support for Severe Exacerbations

• Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with acute hypercapnic respiratory failure who have no absolute contraindications. 1, 2, 3
• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospitalization, and improves survival. 1, 2, 3

Discharge Planning and Prevention

• Initiate maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination) as soon as possible before hospital discharge. 1, 2, 3
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 2, 3
• Schedule follow-up within 3-7 days to assess response. 2
• At 8 weeks post-exacerbation, 20% of patients have not recovered to baseline, necessitating close follow-up. 1, 2, 3
• For patients with ≥2 exacerbations per year despite optimal bronchodilator therapy, consider adding inhaled corticosteroids (if asthma-COPD overlap or high eosinophils), roflumilast (if chronic bronchitis), or macrolide antibiotics (if frequent bacterial exacerbations). 2, 3

Additional Considerations and Pitfalls

• Always differentiate COPD exacerbations from mimics: acute coronary syndrome, heart failure, pulmonary embolism, and pneumonia can present similarly. 1, 3
• Ensure proper inhaler technique when prescribing bronchodilators—check and correct at every visit. 2
• Provide smoking cessation counseling at every visit. 2
• Have patients rinse mouth with water after inhaled corticosteroid use to reduce risk of oropharyngeal candidiasis. 7
• Do not use roflumilast for acute exacerbations—it is only for prevention in severe COPD with chronic bronchitis and history of exacerbations. 3