What is the treatment for a 60-year-old patient with acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

Treatment Prescription for Acute COPD Exacerbation in a 60-Year-Old Patient

For a 60-year-old patient with acute COPD exacerbation, prescribe prednisone 30-40 mg orally daily for 5 days, combined with increased bronchodilator therapy (short-acting beta-agonist with or without ipratropium), and add antibiotics only if the patient presents with at least two of three cardinal symptoms: increased dyspnea, increased sputum volume, AND increased sputum purulence. 1

Systemic Corticosteroids (First-Line Therapy)

Prednisone 30-40 mg orally once daily for 5 days is the evidence-based regimen that reduces treatment failure by over 50% compared to placebo. 1 The REDUCE trial demonstrated that 5-day treatment is non-inferior to 14-day treatment for preventing reexacerbation within 6 months (hazard ratio 0.95,90% CI 0.70-1.29), while significantly reducing cumulative steroid exposure from 793 mg to 379 mg. 2

• Do not taper the corticosteroid dose - tapering is unnecessary and not supported by evidence for short courses. 3
• Do not extend treatment beyond 5-7 days unless the patient fails to respond, as longer courses increase adverse effects without additional clinical benefit. 1, 4
• Oral administration is preferred over IV when the patient can tolerate oral medications. 1

Bronchodilator Therapy (Essential Component)

Increase or initiate short-acting bronchodilators immediately:

• Salbutamol (albuterol) 2.5-5 mg via nebulizer every 4-6 hours OR via metered-dose inhaler with spacer if the patient can use it effectively. 1, 5
• Add ipratropium bromide 500 mcg via nebulizer three times daily if symptoms are severe or response to beta-agonist alone is inadequate. 1, 5
• The inhaled route is preferable to nebulizers for most patients, but ensure the patient can use their inhaler device correctly. 5

Antibiotic Therapy (Selective Use)

Prescribe antibiotics ONLY if the patient has at least TWO of the following three cardinal symptoms:

• Increased dyspnea
• Increased sputum volume
• Development of purulent sputum 5, 1

Recommended antibiotic regimens:

• Amoxicillin 500 mg orally three times daily for 5-7 days OR
• Doxycycline 100 mg orally twice daily for 5-7 days 1

Common pitfall: Avoid prescribing antibiotics reflexively for all COPD exacerbations - they are only beneficial when bacterial infection is likely based on the cardinal symptom criteria. 5

Oxygen Therapy (If Hypoxemic)

• Target SpO₂ of 88-92% to avoid hypercapnic respiratory failure. 1
• Start with 2 L/min via nasal cannula or 28% FiO₂ via Venturi mask until arterial blood gases are obtained. 1
• Do not exceed 28% FiO₂ initially in known COPD patients to prevent CO₂ retention. 1

Sample Prescription

Rx:

1. Prednisone 40 mg tablets

   • Take 1 tablet (40 mg) by mouth once daily for 5 days
   • Dispense: 5 tablets
   • No refills

2. Albuterol 2.5 mg/3 mL nebulizer solution (or MDI 90 mcg/puff with spacer)

   • Nebulize one vial (2.5 mg) every 4-6 hours as needed for shortness of breath
   • Dispense: 30 vials (or 1 MDI inhaler + spacer)
   • Refills: 0

3. Ipratropium bromide 0.5 mg/2.5 mL nebulizer solution (if severe symptoms)

   • Nebulize one vial (0.5 mg) three times daily
   • Can be mixed with albuterol
   • Dispense: 21 vials
   • Refills: 0

4. Amoxicillin 500 mg capsules (ONLY if ≥2 cardinal symptoms present)

   • Take 1 capsule by mouth three times daily for 5 days
   • Dispense: 15 capsules
   • No refills

Critical Assessment Points

Before prescribing, assess for hospital admission criteria:

• Loss of alertness or altered mental status 5
• Severe dyspnea at rest 5
• Inability to manage at home due to inadequate support 5
• Failure to respond to initial treatment 5

Differential diagnoses to exclude:

• Pneumonia, pneumothorax, pulmonary embolism, heart failure, lung cancer - these require different management. 5

Follow-Up Instructions

• Reassess within 48 hours to evaluate treatment response. 5
• If symptoms worsen or fail to improve, consider chest radiograph and hospital referral. 5
• After recovery, optimize maintenance therapy with long-acting bronchodilators (LAMA/LABA combination) to prevent future exacerbations. 1