What is the initial management approach for a patient with chronic obstructive pulmonary disease (COPD) exacerbation?

Initial Management of COPD Exacerbation

Immediately initiate short-acting β2-agonists (SABAs) combined with short-acting anticholinergics (SAMAs) as first-line bronchodilator therapy, administer oral prednisone 40 mg 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

Severity Assessment and Treatment Setting

Determine whether home or hospital management is appropriate based on clinical severity:

• Mild exacerbations (increased symptoms manageable with bronchodilators alone) can be treated at home 2
• Moderate exacerbations (requiring bronchodilators plus antibiotics/corticosteroids) may be managed outpatient 2
• Severe exacerbations require emergency department evaluation or hospitalization, particularly with acute respiratory failure, loss of alertness, or inability to care for self at home 2, 1

Immediate Pharmacological Management

Bronchodilator Therapy

Administer SABAs with or without SAMAs as the cornerstone of acute treatment:

• Use salbutamol 2.5-5 mg combined with ipratropium 0.25-0.5 mg via nebulizer or metered-dose inhaler with spacer 1
• This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 1
• Repeat dosing every 4-6 hours during the acute phase (typically 24-48 hours) until clinical improvement 1
• Nebulizers are preferred in sicker hospitalized patients as they are easier to use and don't require coordination 1
• Avoid methylxanthines (theophylline) due to increased side effects without added benefit 2, 1

Systemic Corticosteroid Protocol

Administer oral prednisone 30-40 mg once daily for exactly 5 days:

• This 5-day course is equally effective as 14-day courses but reduces cumulative steroid exposure by over 50% 1, 3
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1, 3
• Do not extend beyond 5-7 days as this increases adverse effects (hyperglycemia, weight gain, insomnia) without additional benefit 1, 3
• Corticosteroids improve lung function, oxygenation, shorten recovery time, and reduce treatment failure by over 50% 2, 1, 3
• Patients with blood eosinophil count ≥2% show better response, though treatment is recommended regardless of eosinophil levels 3

Antibiotic Therapy

Prescribe antibiotics for 5-7 days when the patient has at least two cardinal symptoms, with increased sputum purulence being one of them:

• Cardinal symptoms: increased dyspnea, increased sputum volume, increased sputum purulence 1
• First-line antibiotics include amoxicillin, amoxicillin/clavulanic acid, tetracycline derivatives, or macrolides based on local resistance patterns 1
• Most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses 1
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1

Hospital Management for Severe Exacerbations

Controlled Oxygenation

Target oxygen saturation of 88-92% (not 90-93%) using controlled oxygen delivery:

• Avoid CO2 retention in COPD patients 1
• Mandatory arterial blood gas measurement within 1 hour of initiating oxygen to assess for worsening hypercapnia 1

Respiratory Support

Initiate noninvasive ventilation (NIV) immediately as first-line therapy for acute hypercapnic respiratory failure:

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates, shortens hospitalization, and improves survival 2, 1
• Contraindications include confusion, large volumes of secretions, or inability to protect airway 1
• Consider invasive mechanical ventilation if NIV fails, particularly in first episode of respiratory failure with demonstrable remedial cause 1

Additional Supportive Measures

• Use diuretics only if peripheral edema and raised jugular venous pressure are present 1
• Administer prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure 1
• Avoid chest physiotherapy in acute exacerbations as there is no evidence of benefit 1
• Monitor fluid balance and nutrition status 1

Maintenance Therapy and Discharge Planning

Initiate or optimize long-acting bronchodilator therapy before hospital discharge:

• Start maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combinations) as soon as possible 2, 1
• Continue existing triple therapy (LAMA/LABA/ICS) unchanged during acute exacerbation if already prescribed 1
• Do not step down from triple therapy during or immediately after exacerbation, as ICS withdrawal increases recurrent exacerbation risk 1

Schedule pulmonary rehabilitation within 3 weeks after discharge:

• Post-discharge rehabilitation reduces hospital readmissions and improves quality of life 1
• Do not start rehabilitation during hospitalization as this increases mortality 1

Follow-Up and Prevention

Schedule follow-up within 3-7 days to assess response:

• Review inhaler technique at every visit 1
• Provide smoking cessation counseling at every visit 1
• Assess for triggers including medication non-adherence and environmental exposures 1
• Consider adding macrolide maintenance therapy (e.g., azithromycin) for patients with ≥2 moderate-to-severe exacerbations per year despite optimal triple therapy 1
• At 8 weeks post-exacerbation, 20% of patients have not recovered to pre-exacerbation state, highlighting importance of continued monitoring 1

Common Pitfalls to Avoid

• Never use systemic corticosteroids beyond 5-7 days for a single exacerbation 1, 3
• Never prescribe antibiotics without appropriate indications (at least two cardinal symptoms with purulence) 1
• Never add a second LAMA to existing triple therapy containing glycopyrrolate, as this constitutes double LAMA therapy without evidence 1
• Never use theophylline in acute exacerbations due to side effect profile 2, 1
• Never delay NIV in patients with acute hypercapnic respiratory failure 2, 1