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

Treatment of COPD Exacerbations

For a COPD exacerbation, initiate treatment with short-acting bronchodilators (beta-agonists with or without anticholinergics), systemic corticosteroids (40 mg prednisone daily for 5 days), and antibiotics if the patient has increased sputum purulence or requires mechanical ventilation. 1

Immediate Pharmacologic Management

Bronchodilators (First-Line)

• Short-acting inhaled beta-2 agonists (SABAs) are the initial bronchodilators recommended, with or without short-acting anticholinergics (SAMAs). 1
• Metered-dose inhalers with spacers are equally effective as nebulizers for drug delivery, though nebulizers may be easier for severely breathless patients. 1
• Avoid intravenous methylxanthines due to increased side effects without added benefit. 1

Systemic Corticosteroids (Essential)

• Administer 40 mg oral prednisone daily for 5 days - this is the evidence-based dose and duration. 1, 2
• Systemic corticosteroids shorten recovery time, improve FEV1 and oxygenation, reduce early relapse risk, and decrease hospitalization length. 1
• Oral prednisolone is equally effective to intravenous administration, making oral the preferred route. 1
• Do not exceed 5-7 days of treatment duration. 1
• Corticosteroids may be less effective in patients with lower blood eosinophil levels. 1

Antibiotics (When Indicated)

Give antibiotics if the patient meets ANY of these criteria: 1

• All three cardinal symptoms present: increased dyspnea, increased sputum volume, AND increased sputum purulence 1
• Two cardinal symptoms present, with increased sputum purulence being one of them 1
• Requires mechanical ventilation (invasive or noninvasive) 1

Antibiotic selection and duration: 1

• First-line empirical choices: aminopenicillin with clavulanic acid, macrolide, or tetracycline 1
• Base selection on local bacterial resistance patterns 1
• Duration: 5-7 days 1
• Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses 1
• For patients with frequent exacerbations, severe airflow limitation, or requiring mechanical ventilation, obtain sputum cultures to identify resistant pathogens. 1
• Procalcitonin-guided therapy may reduce antibiotic exposure while maintaining efficacy. 1

Respiratory Support

Non-Invasive Ventilation (NIV)

• NIV should be the first mode of ventilation for acute respiratory failure in COPD exacerbations (unless absolute contraindications exist). 1
• NIV improves gas exchange, reduces work of breathing, decreases intubation need, shortens hospitalization, and improves survival. 1

Setting of Care

Outpatient vs. Inpatient Management

• More than 80% of exacerbations can be managed outpatient with bronchodilators, corticosteroids, and antibiotics. 1
• Hospitalize for severe exacerbations, defined as those requiring emergency room visit or admission, or those associated with acute respiratory failure. 1

Post-Exacerbation Management

Maintenance Therapy Initiation

• Start long-acting bronchodilator maintenance therapy as soon as possible before hospital discharge. 1
• This prevents subsequent exacerbations and improves long-term outcomes. 1

Common Pitfalls to Avoid

• Do not use methylxanthines - they increase side effects without improving outcomes. 1
• Do not extend corticosteroid duration beyond 5-7 days - longer courses provide no additional benefit and increase adverse effects. 1
• Do not give antibiotics empirically to all patients - reserve for those meeting specific criteria to reduce resistance. 1
• Ensure proper inhaler technique, especially during acute exacerbations when patients are more breathless - consider spacers or nebulizers if technique is compromised. 1