What is the best treatment for a patient with bronchitis and COPD presenting with yellow sputum production and chest pain?

Management of COPD Exacerbation with Yellow Sputum and Chest Pain

This patient requires immediate treatment with antibiotics, systemic corticosteroids, and optimized bronchodilator therapy for an acute exacerbation of COPD with purulent sputum production.

Antibiotic Therapy

Initiate antibiotics immediately given the presence of yellow (purulent) sputum production, which indicates bacterial infection requiring antimicrobial treatment. 1

• First-line options include amoxicillin or tetracycline derivatives for 5-7 days, as these common, inexpensive antibiotics are usually adequate for COPD exacerbations. 1
• Alternatively, amoxicillin/clavulanic acid can be used as first-line therapy. 2
• Short-course therapy (5-7 days) is as effective as longer courses and reduces antimicrobial resistance risk. 2, 3
• For more severe presentations, consider broader spectrum options such as newer cephalosporins, macrolides, or quinolone antibiotics. 2

Systemic Corticosteroid Therapy

Prescribe oral prednisolone 30 mg daily for 7-14 days to improve lung function, oxygenation, and shorten recovery time. 4, 1

• Oral administration is equally effective to intravenous in most cases. 2
• A 2-week course is recommended over longer durations due to significant potential for side effects. 4
• Discontinue corticosteroids after the acute episode unless there is definite indication for long-term treatment. 4

Bronchodilator Optimization

Intensify short-acting bronchodilator therapy immediately:

• Nebulized salbutamol 2.5-5 mg every 4-6 hours should be administered, given she already uses albuterol. 4, 1
• Add ipratropium bromide 0.25-0.5 mg via nebulizer for severe exacerbations or if response to beta-agonist alone is poor. 4, 1
• Continue nebulized bronchodilators for 24-48 hours or until clinically improving, then transition back to metered dose inhalers. 4

Chest Pain Evaluation

The left-sided chest pain (7/10 severity) requires urgent assessment to exclude serious complications:

• Obtain chest X-ray to rule out pneumonia, pneumothorax, or other pulmonary pathology. 2
• Consider cardiac evaluation given the severity and location of pain, especially with her smoking history.
• Monitor oxygen saturation closely. 2

Smoking Cessation Counseling

Provide immediate smoking cessation intervention as she continues to smoke one pack daily, which is the primary driver of disease progression. 5

• Smoking cessation is the single most effective intervention to slow COPD progression. 5

Critical Monitoring Parameters

Assess for signs of respiratory failure:

• Monitor for worsening dyspnea, confusion, or inability to maintain oxygenation. 4
• If pH <7.26 with rising PaCO2 despite treatment, consider ventilatory support (non-invasive or invasive). 4
• Target oxygen saturation of 88-92% if supplemental oxygen is needed. 1

Important Pitfalls to Avoid

• Do not use theophylline during acute exacerbations - it is not recommended and has no proven benefit with significant side effect risk. 4
• Avoid excessive oxygen administration (>28% FiO2 or >2 L/min) until arterial blood gases are known, as this can precipitate respiratory acidosis in COPD patients. 1
• Do not use mucolytic agents or expectorants during acute exacerbations - they are not effective. 4
• Ensure proper inhaler technique before discharge, as this significantly impacts treatment effectiveness. 2