GOLD Recommendations for Acute Exacerbation of COPD
For acute COPD exacerbations, immediately initiate short-acting β2-agonists (SABAs) with or without short-acting anticholinergics as first-line bronchodilators, add systemic corticosteroids (prednisone 40 mg daily for exactly 5 days), and prescribe antibiotics for 5-7 days when increased sputum purulence is present with either increased dyspnea or sputum volume. 1, 2
Severity Classification and Treatment Setting
COPD exacerbations are stratified into three categories that determine management location 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 outpatient 1, 2
- Severe exacerbations: Necessitate hospitalization or emergency department evaluation, often associated with acute respiratory failure 1, 2
Over 80% of exacerbations can be managed in the outpatient setting 2. Hospitalization should be considered for marked symptom intensity, severe underlying COPD, new physical signs, failure of initial outpatient management, significant comorbidities, frequent exacerbations, new arrhythmias, older age, or inability for self-care at home 2.
Immediate Pharmacological Management
Bronchodilator Therapy
Administer SABAs (such as salbutamol 2.5-5 mg) combined with short-acting anticholinergics (such as ipratropium 0.25-0.5 mg) every 4-6 hours during the acute phase. 1, 2 This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 2. Either metered-dose inhalers (with or without spacer) or nebulizers can be used effectively, though nebulizers may be easier for sicker hospitalized patients who cannot coordinate the 20+ inhalations needed to match nebulizer efficacy 1, 2.
Avoid methylxanthines (theophylline) due to increased side effects without added benefit. 1, 2
Systemic Corticosteroid Protocol
Administer oral prednisone 30-40 mg once daily for exactly 5 days starting immediately. 1, 2 This 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.
Systemic corticosteroids improve lung function (FEV1), oxygenation, shorten recovery time and hospitalization duration, and prevent recurrent exacerbations within the first 30 days 1, 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 may be less efficacious in patients with lower blood eosinophil levels 2.
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 Antibiotics reduce the risk of short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 2.
First-line antibiotics include amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid 2. Alternative treatments include newer cephalosporins, macrolides, and quinolone antibiotics, with antibiotic choice based on local bacterial resistance patterns 2. The most common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses 2.
Management of Severe Exacerbations with Respiratory Failure
Oxygen Therapy
Target oxygen saturation of 90-93% using controlled oxygen delivery to avoid CO2 retention. 2 Mandatory arterial blood gas measurement within 1 hour of initiating oxygen is required 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 NIV improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization duration, and improves survival 1, 2.
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, demonstrable remedial cause, or acceptable baseline quality of life 2.
Additional Supportive Measures
Use diuretics only if there is peripheral edema and raised jugular venous pressure 2. Prophylactic subcutaneous heparin is recommended for patients with acute-on-chronic respiratory failure 2. Avoid chest physiotherapy in acute exacerbations as there is no evidence of benefit. 2
Discharge Planning and Post-Exacerbation Management
Initiate or optimize maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combinations) as soon as possible before hospital discharge. 1, 2 Continue existing triple therapy (LAMA/LABA/ICS) unchanged during and after the acute exacerbation, as there is no evidence to support escalation or modification of maintenance therapy acutely 2.
Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 1, 2 Starting rehabilitation during hospitalization increases mortality, while post-discharge timing reduces admissions 2.
Schedule follow-up within 3-7 days to assess response 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.
Prevention of Future Exacerbations
After an exacerbation, appropriate measures for exacerbation prevention should be initiated 1. Patients with frequent exacerbations (≥2 per year) have worse health status and morbidity, requiring more aggressive preventive strategies 2.
For patients who continue to experience ≥2 exacerbations per year despite optimized triple therapy, consider adding prophylactic macrolide therapy (e.g., azithromycin) in former smokers. 2 For patients with chronic bronchitic phenotype (chronic cough and sputum production), consider roflumilast or N-acetylcysteine 2.
Smoking cessation counseling should be provided at every visit 2. Review inhaler technique to ensure proper use and adherence to treatment 2.
Common Pitfalls to Avoid
Do not step down from triple therapy during or immediately after an exacerbation, as ICS withdrawal increases the risk of recurrent moderate-severe exacerbations, particularly in patients with eosinophils ≥300 cells/μL 2. Do not use systemic corticosteroids beyond 5-7 days for a single exacerbation 2. Do not delay NIV in patients with acute hypercapnic respiratory failure 2.