What is the management plan for a patient experiencing a chronic obstructive pulmonary disease (COPD) exacerbation?

COPD Exacerbation Management

Immediately initiate short-acting bronchodilators (beta-agonists combined with anticholinergics), systemic corticosteroids (prednisone 30-40 mg daily for exactly 5 days), controlled oxygen therapy targeting 88-92% saturation, and antibiotics if two or more cardinal symptoms are present—this combination reduces mortality, shortens hospitalization, and prevents treatment failure. 1

Initial Assessment and Severity Stratification

Obtain arterial blood gas analysis within 60 minutes of presentation to assess for hypercapnia and respiratory acidosis, along with chest radiograph, ECG, and basic laboratory studies 2. Severity determines treatment setting:

• Mild exacerbations: Managed outpatient with bronchodilators alone 1
• Moderate exacerbations: Outpatient management with bronchodilators plus antibiotics and/or corticosteroids 1
• Severe exacerbations: Require hospitalization, particularly with acute respiratory failure, loss of alertness, severe dyspnea, or inability to maintain adequate oxygenation 1, 3

Oxygen Therapy

Target oxygen saturation of 88-92% using controlled delivery via Venturi mask (FiO2 ≤28%) or nasal cannula (≤2 L/min) until arterial blood gases are known 1, 2. This prevents CO2 retention while correcting hypoxemia. Recheck arterial blood gases within 60 minutes of initiating oxygen and after any change in oxygen concentration 2. High-flow oxygen worsens hypercapnic respiratory failure and increases mortality 3.

Bronchodilator Therapy

Administer nebulized short-acting beta-agonists (salbutamol 2.5-5 mg or terbutaline 5-10 mg) combined with short-acting anticholinergics (ipratropium bromide 0.25-0.5 mg) immediately upon arrival 4, 1. This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 1.

• Nebulizers should be driven by compressed air (not oxygen) if PaCO2 is elevated or respiratory acidosis is present 4
• Oxygen can continue via nasal prongs at 1-2 L/min during nebulization to prevent desaturation 4
• Repeat dosing every 4-6 hours for 24-48 hours until clinical improvement occurs 4, 1
• Transition to metered-dose inhalers once improving clinically 4

Avoid intravenous methylxanthines (theophylline) due to increased side effects without added benefit 1, 2. The FDA label confirms theophylline is a relatively weak bronchodilator, less effective than inhaled beta-agonists, and provides no added benefit in acute bronchospasm 5.

Systemic Corticosteroid Protocol

Administer oral prednisone 30-40 mg once daily for exactly 5 days starting immediately 1, 2. This duration is equally effective as 14-day courses but reduces cumulative steroid exposure by over 50% 1. Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1.

Discontinue corticosteroids after 5-7 days unless there is a separate indication for long-term treatment 4, 2. An exacerbation while on corticosteroids does not indicate need for long-term inhaled corticosteroids 4.

Antibiotic Therapy

Prescribe antibiotics for 5-7 days when the patient has at least two of the following cardinal symptoms: increased dyspnea, increased sputum volume, or increased sputum purulence 1, 2. Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1.

First-line antibiotic choices include amoxicillin, amoxicillin/clavulanic acid, tetracycline derivatives, or macrolides, based on local bacterial resistance patterns 1, 2. The most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1.

Respiratory Support for Severe Exacerbations

Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with pH <7.35 with rising PaCO2 who fail to respond to initial treatment, or those with acute hypercapnic respiratory failure 4, 1, 2. NIV improves gas exchange, reduces work of breathing, decreases intubation rates by 80-85%, shortens hospitalization duration, and improves survival 1, 2.

Contraindications to NIV include confusion, large volume of secretions, loss of alertness, or inability to protect airway 4, 1. Consider invasive mechanical ventilation if NIV fails 2.

Additional Supportive Measures

• Diuretics: Indicated only if peripheral edema and raised jugular venous pressure are present 4, 2
• Prophylactic subcutaneous heparin: Recommended for patients with acute-on-chronic respiratory failure 4, 2
• Avoid chest physiotherapy: Not recommended in acute COPD exacerbations, as there is no evidence of benefit 4

Discharge Planning and Follow-Up

Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life 1, 3. Do not initiate pulmonary rehabilitation during hospitalization, as this increases mortality 1, 3.

Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or combination) before hospital discharge 1. Continue existing triple therapy unchanged during the acute exacerbation 1.

Arrange follow-up within 3-7 days to assess response to treatment, review inhaler technique, provide smoking cessation counseling, and develop strategies to prevent future exacerbations 1, 2.

Critical Pitfalls to Avoid

• Never use high-flow oxygen without arterial blood gas monitoring in COPD patients, as this worsens hypercapnia and increases mortality 3
• Never continue systemic corticosteroids beyond 5-7 days for a single exacerbation, as risks outweigh benefits 1
• Never delay NIV in patients with acute hypercapnic respiratory failure and pH <7.35 1
• Never power nebulizers with oxygen if PaCO2 is elevated or respiratory acidosis is present—use compressed air instead 4
• Never start pulmonary rehabilitation during hospitalization—wait until 3 weeks post-discharge 1, 3