What is the management plan for a patient with an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) or bronchial asthma?

Management of Acute Exacerbation of COPD and Acute Exacerbation of Bronchial Asthma

Acute Exacerbation of COPD

Initial Assessment and Oxygen Therapy

For COPD exacerbations, immediately initiate controlled oxygen therapy targeting SpO₂ 88-92%, as uncontrolled oxygen can worsen hypercapnia and respiratory acidosis. 1

• Start with 28% Venturi mask or 2 L/min via nasal cannulae in patients aged ≥50 years with known COPD until arterial blood gases are obtained 1
• Check arterial blood gases within 60 minutes of starting oxygen and within 60 minutes of any change in FiO₂ 1
• If pH falls below 7.26 (secondary to rising PaCO₂), consider non-invasive ventilation rather than increasing oxygen 1
• A pH <7.26 predicts poor outcome and warrants intensive monitoring 1

Bronchodilator Therapy

Nebulized short-acting β₂-agonists with or without anticholinergics are the cornerstone of acute bronchodilator therapy. 1

• For moderate exacerbations: Give either salbutamol 2.5-5 mg OR ipratropium bromide 0.25-0.5 mg via nebulizer 1
• For severe exacerbations or poor response: Combine both agents 1
• Administer every 4-6 hours initially, but may use more frequently if required 1
• Critical pitfall: Drive nebulizers with compressed air (not oxygen) if PaCO₂ is elevated or respiratory acidosis is present 1, 2
• Provide supplemental oxygen at 1-2 L/min via nasal prongs during nebulization to prevent desaturation 1, 2
• Continue for 24-48 hours or until clinical improvement, then transition to metered-dose inhalers 1

Systemic Corticosteroids

Administer oral prednisolone 30-40 mg daily for 5 days—this short course is as effective as longer regimens while minimizing adverse effects. 1, 3, 2

• Oral route is strongly preferred over intravenous administration 3, 2
• If oral route impossible (vomiting, inability to swallow), use IV hydrocortisone 100 mg or IV methylprednisolone 40 mg daily 1, 3, 2
• Do not extend beyond 5-7 days routinely—longer courses increase adverse effects (hyperglycemia, weight gain, insomnia) without additional benefit 3, 2
• Blood eosinophil count ≥2% predicts better response, but treat all exacerbations requiring emergent care regardless of eosinophil levels 3
• Discontinue after acute episode unless definite indication for long-term treatment exists 1, 3

Antibiotic Therapy

Prescribe antibiotics when patients present with increased sputum purulence plus at least one other cardinal symptom (increased dyspnea or increased sputum volume), or when mechanical ventilation is required. 1

• First-line: Amoxicillin-clavulanate, macrolide, or tetracycline 1
• For severe exacerbations with frequent prior exacerbations or FEV₁ <50% predicted, obtain sputum cultures to identify resistant pathogens 1
• Recommended duration: 5-7 days 1

Ventilatory Support

Non-invasive ventilation (NIV) is the preferred initial mode of ventilation for patients with pH <7.26 and rising PaCO₂ who fail to respond to initial therapy. 1

• NIV reduces mortality, intubation rates, and hospital length of stay with 80-85% success rate 1
• Contraindications to NIV: Confusion, large volume of secretions, inability to protect airway 1
• Invasive mechanical ventilation indicated if NIV fails 1
• Patients failing NIV and requiring subsequent invasive ventilation have higher morbidity and mortality 1

Medications to Avoid

• Methylxanthines (theophylline, aminophylline) are NOT recommended due to unfavorable side effect profile without proven benefit 1, 4
• Long-acting bronchodilators and mucolytics have no proven value in acute treatment 5

Discharge Planning

Initiate maintenance therapy with long-acting bronchodilators (LABA/LAMA or ICS/LABA combinations) before hospital discharge to prevent future exacerbations. 1

• Schedule early follow-up within 30 days—this reduces exacerbation-related readmissions 1
• Verify inhaler technique before discharge 3
• Ensure adequate home support, especially for elderly patients 3

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Acute Exacerbation of Bronchial Asthma

Initial Bronchodilator Therapy

Administer high-dose inhaled short-acting β₂-agonists immediately—this is first-line therapy for acute asthma exacerbations. 4

• Salbutamol 2.5-5 mg via nebulizer or 4-8 puffs via metered-dose inhaler with spacer 4
• Repeat every 20 minutes for first hour if needed 4
• For severe exacerbations, continuous nebulization may be required 4
• Unlike COPD, nebulizers can be oxygen-driven in asthma as hypercapnic respiratory failure is less common 4

Systemic Corticosteroids

Give oral prednisolone 40-50 mg (or IV hydrocortisone 100 mg if oral route unavailable) immediately—corticosteroids are the second pillar of acute asthma management. 4

• Systemic steroids have anti-inflammatory effects and reduce relapse rates 4
• Continue for 5-7 days for most exacerbations 3
• Oral and IV routes are equally effective; choose oral when possible 3

Oxygen Therapy

Target SpO₂ 94-98% in acute asthma (higher than COPD target) as hypercapnic respiratory failure is uncommon in asthma. 4

• Titrate oxygen to maintain adequate saturation 4
• Monitor for clinical signs of impending respiratory failure: inability to speak in full sentences, use of accessory muscles, altered mental status 4

Additional Therapies for Severe Exacerbations

• Ipratropium bromide 0.5 mg can be added to β₂-agonists in severe exacerbations 6
• IV magnesium sulfate is a possible additional option for severe asthma attacks 4
• Invasive ventilation remains last resort for patients with clinical signs of impending exhaustion 4

Key Differences from COPD Management

• Asthma exacerbations typically respond more rapidly to bronchodilators than COPD 4
• Oxygen targets are higher (94-98% vs 88-92%) 4
• Hypercapnic respiratory failure is less common, so oxygen-driven nebulizers are acceptable 4
• Theophylline plays even less of a role in asthma than COPD 4

Critical Pitfall

A history of asthma is a contraindication to any β-blocker use—if patients are on β-blockers for cardiac conditions, these must be carefully evaluated and potentially discontinued during acute exacerbations. 7