COPD Exacerbation Management
For a patient experiencing a COPD exacerbation, immediately initiate short-acting inhaled β2-agonists combined with short-acting anticholinergics, systemic corticosteroids (prednisone 40 mg daily for 5 days), and antibiotics (5-7 days) if there is increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2, 3
Initial Assessment and Severity Classification
COPD exacerbations are classified by severity, which determines treatment setting and intensity 1:
- Mild exacerbations: Treated with short-acting bronchodilators only, managed outpatient 1, 2
- Moderate exacerbations: Require short-acting bronchodilators plus antibiotics and/or oral corticosteroids, typically managed outpatient 1, 2
- Severe exacerbations: Require hospitalization or emergency department visit, may be associated with acute respiratory failure 1, 2
Indications for hospitalization include: marked increase in dyspnea, inability to eat or sleep due to symptoms, worsening hypoxemia or hypercapnia, changes in mental status, inability to care for oneself, uncertain diagnosis, or inadequate home support 1, 2
Pharmacological Management
Bronchodilator Therapy
Short-acting inhaled β2-agonists (SABAs) with or without short-acting anticholinergics are the cornerstone of acute treatment. 1, 2, 3 The combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 2, 3. Typical dosing includes salbutamol 2.5-5 mg combined with ipratropium 0.25-0.5 mg, repeated every 4-6 hours during the acute phase 2, 3.
Either metered-dose inhalers (with spacer) or nebulizers can be used effectively 1, 2. However, nebulizers are preferred in sicker hospitalized patients because they are easier to use and don't require the coordination needed for 20+ inhalations to match nebulizer efficacy 2. The FDA label for ipratropium notes that bronchodilation occurs within 15-30 minutes, peaks at 1-2 hours, and persists for 4-5 hours 4.
Important caveat: Methylxanthines (theophylline) are not recommended 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. 1, 2, 3 This regimen improves lung function (FEV1), oxygenation, shortens recovery time, and reduces hospitalization duration 1, 2. A 5-day course is equally effective as 14-day courses but reduces cumulative steroid exposure by over 50% 2.
Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 2. Do not continue corticosteroids beyond 5-7 days after the acute episode unless there is a separate indication for long-term treatment 2. Corticosteroids prevent hospitalization for subsequent exacerbations within the first 30 days but provide no benefit beyond this window 2.
Antibiotic Therapy
Antibiotics should be prescribed for 5-7 days when the patient has increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2, 3 This approach reduces short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 2.
The most common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses 1, 2. First-line antibiotics include amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid 1, 2, 3. Alternative treatments include newer cephalosporins, macrolides, and quinolone antibiotics, with choice based on local bacterial resistance patterns 1, 2.
Respiratory Support for Severe Exacerbations
Oxygen Therapy
Target oxygen saturation of 88-92% (or PaO2 ≥60 mmHg/8 kPa) using controlled oxygen delivery to avoid CO2 retention. 1, 2, 3 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 3. Arterial blood gas measurement is mandatory within 1 hour of initiating oxygen to assess for worsening hypercapnia 2.
Noninvasive Ventilation (NIV)
NIV should be the first mode of ventilation for patients with acute hypercapnic respiratory failure who have no absolute contraindication. 1, 2, 3 NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 65%, shortens hospitalization duration, and improves survival 1, 2, 3.
Indications for NIV include acute respiratory failure with persistent hypoxemia despite oxygen, severe dyspnea with respiratory muscle fatigue, or pH <7.35 with PaCO2 >45 mmHg 2. Common pitfall: Confused patients and those with large volumes of secretions are less likely to respond well to NIV 2. Consider invasive mechanical ventilation if NIV fails, particularly in patients with a first episode of respiratory failure or demonstrable remedial cause 2.
Discharge Planning and Prevention
Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge. 1, 2 Patients should not step down from triple therapy (LAMA/LABA/ICS) during or immediately after an exacerbation, as ICS withdrawal increases recurrent exacerbation risk 2.
Schedule pulmonary rehabilitation within 3 weeks after discharge, as this reduces hospital readmissions and improves quality of life 2. Starting rehabilitation during hospitalization increases mortality, while post-discharge timing reduces admissions 2.
Follow-up visit after an acute exacerbation provides an opportunity to initiate appropriate measures for exacerbation prevention, including smoking cessation counseling, medication review, and inhaler technique verification 1, 2. At 8 weeks after an exacerbation, 20% of patients have not recovered to their pre-exacerbation state, highlighting the importance of follow-up care 2.
For patients with frequent exacerbations (≥2 per year) despite optimized triple therapy, consider adding macrolide maintenance therapy (e.g., azithromycin) or roflumilast/N-acetylcysteine for those with chronic bronchitic phenotype 2.