What is the best approach for inpatient management of a chronic obstructive pulmonary disease (COPD) exacerbation?

Inpatient Management of COPD Exacerbation

For hospitalized COPD exacerbation patients, immediately initiate combined nebulized short-acting β2-agonists (albuterol 2.5-5 mg) plus short-acting anticholinergics (ipratropium 0.25-0.5 mg) every 4-6 hours, oral prednisone 30-40 mg daily for exactly 5 days, controlled oxygen targeting SpO2 88-92%, and noninvasive ventilation for acute hypercapnic respiratory failure. 1, 2, 3

Immediate Assessment and Oxygen Management

Perform pulse oximetry immediately upon arrival and obtain arterial blood gases if SpO2 <90% or if respiratory acidosis is suspected. 1, 2, 3

• Target oxygen saturation of 88-92% using controlled oxygen delivery (Venturi mask preferred), as higher oxygen concentrations can worsen hypercapnic respiratory failure and increase mortality in COPD patients. 2, 3, 4
• Mandatory repeat arterial blood gas measurement within 60 minutes of initiating oxygen therapy to assess for worsening hypercapnia (rising PaCO2) or acidosis (pH <7.35). 1, 2, 3
• If initial ABG shows acidosis or hypercapnia, repeat measurements anytime the clinical situation deteriorates. 3

Bronchodilator Therapy

Administer nebulized albuterol 2.5-5 mg combined with ipratropium bromide 0.25-0.5 mg immediately upon presentation. 2, 3, 4

• The combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone. 2
• Continue nebulized bronchodilators every 4-6 hours for 24-48 hours until clinical improvement occurs, then transition to metered-dose inhalers 24-48 hours before discharge. 2, 3
• Nebulizers are preferred over metered-dose inhalers in sicker hospitalized patients because they require no coordination and deliver equivalent doses without requiring 20+ inhalations. 2
• If PaCO2 is elevated or respiratory acidosis is present, drive nebulizers with compressed air rather than oxygen. 3
• Avoid methylxanthines (theophylline/aminophylline) as they increase side effects without added benefit. 1, 2, 4

Systemic Corticosteroid Protocol

Administer oral prednisone 30-40 mg once daily for exactly 5 days starting immediately upon admission. 1, 2, 3, 4

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake. 1, 2
• A 5-day course is equally effective as 14-day courses but reduces cumulative steroid exposure by over 50%. 2
• Do not continue corticosteroids beyond 5-7 days after the acute episode unless there is a separate indication for long-term treatment. 2, 3
• Corticosteroids improve lung function, oxygenation, shorten recovery time, reduce treatment failure by over 50%, and prevent recurrent exacerbations within the first 30 days. 2

Antibiotic Therapy

Prescribe antibiotics for 5-7 days if the patient has at least two of the following cardinal symptoms: increased dyspnea, increased sputum volume, or increased sputum purulence. 1, 2, 4

• First-line antibiotics include amoxicillin, amoxicillin/clavulanic acid, doxycycline, or macrolides (azithromycin) based on local bacterial resistance patterns. 2, 4
• The most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 2, 4
• Alternative treatments for more severe cases include newer cephalosporins or fluoroquinolone antibiotics. 2

Respiratory Support for Severe Exacerbations

Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with acute hypercapnic respiratory failure (pH <7.35), persistent hypoxemia despite oxygen, or severe dyspnea with respiratory muscle fatigue. 1, 2, 3, 4

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospitalization duration, and improves survival. 1, 2, 4
• Do not delay NIV in patients meeting criteria, as early initiation is critical for success. 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

Diagnostic Testing

Obtain chest radiograph on all hospitalized patients to exclude alternative diagnoses, as chest X-ray changes management in 7-21% of cases by identifying pneumonia, pneumothorax, or pulmonary edema. 1, 3

• Perform ECG if resting heart rate <60/min or >110/min, or if cardiac symptoms are present. 1, 3
• Blood tests are not routinely required but should be available if indicated by clinical assessment. 3

Additional Supportive Measures

• Use diuretics only if there is peripheral edema and raised jugular venous pressure, not routinely. 2, 4
• Administer prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure to prevent venous thromboembolism. 2
• Avoid chest physiotherapy in acute exacerbations of COPD, as there is no evidence of benefit. 2, 4
• Monitor fluid balance and nutrition status throughout hospitalization. 2

Discharge Planning and Follow-Up

Continue maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combinations) unchanged during the acute exacerbation and optimize before discharge. 2

• Do not step down from triple therapy (LAMA/LABA/ICS) during or immediately after exacerbation, as ICS withdrawal increases recurrent exacerbation risk, particularly in patients with eosinophils ≥300 cells/μL. 2
• Measure FEV1 before discharge to establish a new baseline. 3
• Check arterial blood gases on room air before discharge in patients who presented with respiratory failure. 3
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 1, 2, 3, 4
• Do not initiate pulmonary rehabilitation during hospitalization, as this increases mortality; wait until post-discharge. 1, 2, 3
• Provide intensive smoking cessation counseling with nicotine replacement therapy and behavioral intervention at every visit for current smokers. 2
• Review and correct inhaler technique before discharge. 2

Indications for ICU Admission

Transfer to ICU if the patient develops: 4

• Impending or actual respiratory failure despite NIV
• Hemodynamic instability or shock
• Other end-organ dysfunction (renal, hepatic, or neurological disturbance)
• Inability to maintain pH >7.26 despite maximal therapy

Common Pitfalls to Avoid

• Avoid high-flow oxygen (FiO2 >28%) until ABGs are known in COPD patients, as uncontrolled oxygen worsens hypercapnic respiratory failure. 3, 4
• Do not use intravenous corticosteroids without clear indication (inability to tolerate oral), as oral is equally effective. 1, 2
• Do not continue systemic corticosteroids beyond 5-7 days for a single exacerbation. 2, 3
• Do not delay NIV in patients with acute hypercapnic respiratory failure. 2
• Do not use sedatives, which can worsen respiratory depression. 3