What is the initial treatment plan for a patient experiencing a Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

Treatment Plan for COPD Exacerbation

Immediately initiate short-acting β2-agonists (SABAs) combined with short-acting anticholinergics (SAMAs) as first-line bronchodilator therapy, add prednisone 40 mg orally daily for exactly 5 days, and prescribe antibiotics for 5-7 days if the patient has increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2

Bronchodilator Therapy

Initial bronchodilation is the cornerstone of acute management:

• Administer SABA (albuterol) with or without SAMA (ipratropium) immediately upon presentation via nebulizer or metered-dose inhaler with spacer 1, 2
• Nebulizers are preferred in sicker hospitalized patients because they are easier to use and don't require the coordination needed for 20+ inhalations from an MDI to match nebulizer efficacy 1
• Dose every 4-6 hours during the acute phase, though more frequent dosing may be required based on clinical response 1, 2
• Combined SABA/SAMA therapy provides superior bronchodilation compared to either agent alone, with effects lasting 4-6 hours 1
• Avoid intravenous methylxanthines (theophylline) due to increased side effects without added benefit 1, 2

Systemic Corticosteroid Protocol

Corticosteroids are essential for reducing treatment failure and accelerating recovery:

• Prescribe prednisone 30-40 mg orally once daily for exactly 5 days starting immediately 1, 2
• Do not exceed 5-7 days duration to minimize cumulative steroid exposure while maintaining efficacy 1, 2
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1
• Systemic corticosteroids improve lung function, oxygenation, shorten recovery time, and reduce hospitalization duration 1, 2
• They prevent recurrent exacerbations within the first 30 days but provide no benefit beyond this window 1
• Corticosteroids may be less effective in patients with lower blood eosinophil levels 1

Antibiotic Therapy

Antibiotics should be prescribed based on cardinal symptom assessment:

• Prescribe antibiotics for 5-7 days if the patient has increased sputum purulence PLUS either increased dyspnea OR increased sputum volume 1, 2
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1
• First-line options include amoxicillin, amoxicillin/clavulanic acid, tetracycline derivatives, or macrolides based on local bacterial resistance patterns 1, 2
• Common causative organisms include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
• Alternative treatments include newer cephalosporins and quinolone antibiotics 1

Oxygen Therapy (If Hypoxemic)

Controlled oxygen delivery is critical to avoid CO2 retention:

• Target oxygen saturation of 88-92% (or 90-93%) using controlled oxygen delivery 1, 2
• In patients with known COPD aged 50 years or older, initial FiO2 should not exceed 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known 2
• Obtain mandatory arterial blood gas measurement within 1 hour of initiating oxygen to assess for worsening hypercapnia 1, 2
• Aim for PaO2 of at least 6.6 kPa or SpO2 ≥90% without causing respiratory acidosis 2

Respiratory Support for Severe Exacerbations

Noninvasive ventilation is first-line for acute respiratory failure:

• Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with acute hypercapnic respiratory failure who have no absolute contraindication 1, 2
• NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization duration, and improves survival 1, 2

Treatment Setting Determination

Most exacerbations can be managed outpatient, but specific criteria warrant hospitalization:

• More than 80% of exacerbations can be managed on an outpatient basis 1
• Hospitalize for: severe exacerbations with acute respiratory failure, 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, 2

Maintenance Therapy Continuation

Do not modify existing maintenance therapy during the acute exacerbation:

• Continue existing triple therapy (LAMA/LABA/ICS) unchanged during the acute exacerbation, as there is no evidence to support escalation or modification of maintenance therapy acutely 1
• Initiate or optimize maintenance therapy with long-acting bronchodilators as soon as possible before hospital discharge 1

Follow-Up and Prevention

Post-exacerbation care is essential to prevent recurrence:

• Schedule follow-up within 3-7 days for outpatients to assess response 1
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life (starting during hospitalization increases mortality) 1
• Provide smoking cessation counseling at every visit 1
• Review and correct inhaler technique 1
• For patients with ≥2 exacerbations per year despite optimal triple therapy, consider adding prophylactic macrolide therapy (e.g., azithromycin) 1, 3
• 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