What medications are typically given to a patient experiencing a Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

Medications for COPD Exacerbation

For a COPD exacerbation, immediately initiate three medication classes: short-acting bronchodilators (beta-agonists with or without anticholinergics), systemic corticosteroids (prednisone 40 mg daily for 5 days), and antibiotics (if increased sputum purulence is present). 1, 2

Bronchodilator Therapy

Short-acting inhaled β2-agonists (SABAs) combined with short-acting anticholinergics provide superior bronchodilation and should be the initial bronchodilator treatment for all acute exacerbations. 1, 2

• Administer albuterol 2.5-5 mg combined with ipratropium 0.25-0.5 mg every 4-6 hours during the acute phase until clinical improvement occurs (typically 24-48 hours). 2
• Either metered-dose inhalers with spacer or nebulizers deliver equivalent efficacy, though nebulizers are preferred for sicker patients who cannot coordinate 20+ inhalations needed to match nebulizer dosing. 1, 2
• Avoid intravenous methylxanthines (theophylline) due to increased side effects without added benefit. 1, 2

Systemic Corticosteroids

Prednisone 40 mg orally once daily for exactly 5 days is the evidence-based standard regimen. 1, 2

• Systemic corticosteroids shorten recovery time, improve FEV1 and oxygenation, reduce risk of early relapse by over 50%, decrease treatment failure, and shorten hospitalization duration. 1, 2
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake. 1, 2
• Do not extend corticosteroid therapy beyond 5-7 days, as longer courses provide no additional benefit and increase adverse effects. 1, 2, 3
• Corticosteroids may be less effective in patients with lower blood eosinophil levels. 1

Antibiotic Therapy

Prescribe antibiotics for 5-7 days when the patient has increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2, 3

• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44%. 1
• First-line antibiotic choices include amoxicillin, amoxicillin-clavulanate, doxycycline, or macrolides, with selection based on local bacterial resistance patterns. 2, 3
• The most common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses. 2

Respiratory Support for Severe Exacerbations

Noninvasive ventilation (NIV) should be the first-line ventilation mode for patients with acute hypercapnic respiratory failure who have no absolute contraindication. 1, 2

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates, shortens hospitalization duration, and improves survival. 1, 2
• Target oxygen saturation of 88-92% using controlled oxygen delivery to avoid CO2 retention. 2
• Obtain arterial blood gas within 1 hour of initiating oxygen therapy to assess for worsening hypercapnia. 2

Treatment Setting

More than 80% of COPD exacerbations can be managed in the outpatient setting with the combination of bronchodilators, corticosteroids, and antibiotics. 1, 2, 3

Hospitalization is indicated for:

• Severe exacerbations with acute respiratory failure 2
• Marked increase in symptom intensity 2
• New physical signs (cyanosis, peripheral edema) 2
• Failure to respond to initial outpatient management 2
• Significant comorbidities or inability to care for self at home 2

Critical Pitfalls to Avoid

• Never prescribe corticosteroids beyond 5-7 days for a single exacerbation. 1, 2
• Never use theophylline in acute exacerbations due to its side effect profile without added benefit. 1, 2
• Never delay NIV in patients with acute hypercapnic respiratory failure. 2
• Never prescribe antibiotics prophylactically; reserve them for exacerbations with purulent sputum. 3
• Never step down from triple maintenance therapy during or immediately after an exacerbation, as ICS withdrawal increases recurrent exacerbation risk. 2

Post-Exacerbation Management

• Continue or optimize long-acting bronchodilator maintenance therapy before hospital discharge. 2
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 2
• Arrange follow-up within 3-7 days to assess response and optimize prevention strategies. 2