Management of Acute COPD Exacerbation
Immediately initiate short-acting bronchodilators, prescribe oral prednisone 40 mg daily for exactly 5 days, and add antibiotics only when there is increased sputum purulence plus either increased dyspnea or increased sputum volume. 1
Initial Assessment and Monitoring
Obtain arterial blood gases immediately to assess oxygenation and acid-base status, perform chest radiograph to exclude pneumonia, pneumothorax, or pulmonary edema, and complete blood count, electrolytes, and ECG within 24 hours 2. Repeat arterial blood gases within 60 minutes of starting oxygen therapy and whenever clinical deterioration occurs 3, 2.
Send sputum for culture if purulent, particularly in patients with frequent exacerbations, severe airflow limitation, or those requiring mechanical ventilation to identify resistant pathogens 3, 2.
Oxygen Therapy
Target oxygen saturation of 88-92% to avoid worsening hypercapnia and respiratory acidosis 3, 2. Start with controlled oxygen delivery at FiO2 ≤28% via Venturi mask or ≤2 L/min via nasal cannulae until arterial blood gases are known 2, 1.
Check blood gases within 60 minutes of any change in inspired oxygen concentration 3, 2. Gradually increase oxygen only if responding without acid-base deterioration 2. Avoid uncontrolled high-flow oxygen which may precipitate hypercapnic respiratory failure 2.
Bronchodilator Therapy
Administer nebulized short-acting bronchodilators immediately on arrival and continue at 4-6 hourly intervals 2, 1. Use salbutamol 2.5-5 mg or terbutaline 5-10 mg as first-line therapy 1.
For moderate exacerbations, use either a beta-agonist or anticholinergic (ipratropium bromide 0.25-0.5 mg) alone; for severe exacerbations or poor response to monotherapy, combine both agents 3, 1. Ensure nebulizers are driven by compressed air (not oxygen) if the patient has hypercapnia and/or respiratory acidosis 2.
Continue nebulized bronchodilators for 24-48 hours until clinical improvement, then transition to metered-dose inhalers 24-48 hours before discharge 2, 1.
Systemic Corticosteroid Protocol
Prescribe oral prednisone 40 mg daily for exactly 5 days—this duration is non-inferior to 14 days for preventing reexacerbation while significantly reducing cumulative steroid exposure 1. Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 3, 1.
For hospitalized patients unable to take oral medication, use 100 mg hydrocortisone IV or 30-40 mg methylprednisolone IV daily 2, 1. Discontinue corticosteroids after 5 days unless there is documented benefit during stable disease—do not continue long-term based solely on an exacerbation 3, 1.
Antibiotic Therapy
Prescribe antibiotics only when two or more of the following are present: (1) increased dyspnea, (2) increased sputum volume, (3) purulent sputum 3, 1. Antibiotics should also be given to patients requiring mechanical ventilation (invasive or noninvasive) 3.
Treat for 5-7 days with aminopenicillin plus clavulanic acid, a macrolide (azithromycin 500 mg daily for 3 days), or a tetracycline, based on local resistance patterns 3, 1, 4. In patients with frequent exacerbations or severe airflow limitation, consider broader-spectrum agents and obtain cultures 3.
Ventilatory Support
Non-Invasive Ventilation (NIV)
Initiate NIV as first-line ventilatory support for patients with pH <7.26 and rising PaCO2 despite standard medical management 3, 2, 1. NIV reduces mortality and intubation rates by 80-85% 3, 5.
Avoid NIV in patients with confusion, large volume of secretions, or hemodynamic instability 2. Consider invasive mechanical ventilation if NIV fails 3, 2.
Invasive Mechanical Ventilation
The indication for invasive ventilation includes failure of initial NIV trial 3. Patients who fail NIV and receive invasive ventilation as rescue therapy have greater morbidity, longer hospital stays, and higher mortality 3.
Additional Interventions
Administer diuretics if peripheral edema and elevated jugular venous pressure are present 3, 2, 1. Give prophylactic subcutaneous heparin for thromboembolism prevention in patients with acute-on-chronic respiratory failure 2, 1.
Consider intravenous methylxanthines by continuous infusion only if the patient is not responding to current therapy, and monitor blood levels daily if used 2. Do not use chest physiotherapy for acute exacerbations as there is insufficient evidence of benefit 1.
Criteria for Hospital Admission
Hospitalize when any of the following are present: loss of alertness or confusion, severe dyspnea with use of accessory muscles, paradoxical chest wall movements, cyanosis, new or worsening peripheral edema, hemodynamic instability, inability to cope at home, inadequate social support, or failure to respond to initial outpatient treatment 5, 1.
Consider admission to ICU or intermediate respiratory care unit for patients with severe exacerbations requiring ventilatory support 3.
Discharge Planning and Follow-Up
Measure FEV1 and check arterial blood gases on room air before discharge in patients who presented with respiratory failure 1. Ensure adequate spirometric assessment as lack of this has been associated with rehospitalization and mortality 3.
Schedule early follow-up within 30 days after discharge—this has been related to fewer exacerbation-related readmissions 3, 2. Patients not attending early follow-up have increased 90-day mortality 3.
Initiate pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life—starting during hospitalization increases mortality 1. Additional follow-up at 3 months is recommended to ensure return to stable state and review symptoms, lung function, and comorbidities 3.
Common Pitfalls to Avoid
- Do not prescribe antibiotics empirically without meeting the criteria of increased sputum purulence plus either increased dyspnea or sputum volume 3, 1
- Avoid prolonged corticosteroid courses beyond 5 days without specific indication—this increases adverse effects without additional benefit 1
- Never use uncontrolled high-flow oxygen in patients with known COPD—this can worsen hypercapnia and precipitate respiratory failure 2
- Do not use sedatives which worsen respiratory depression 1
- Avoid delaying hospital evaluation when severity is uncertain—err on the side of caution 1