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

Treatment for COPD Exacerbation

Immediately initiate short-acting bronchodilators (SABA with or without SAMA), oral prednisone 30-40 mg daily for exactly 5 days, and antibiotics for 5-7 days if the patient has increased sputum purulence plus either increased dyspnea or increased sputum volume. 1

Immediate Bronchodilator Therapy

Administer short-acting β2-agonists (salbutamol 2.5-5 mg) combined with short-acting anticholinergics (ipratropium 0.25-0.5 mg) via nebulizer or metered-dose inhaler with spacer every 4-6 hours during the acute phase. 1 This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone. 1 Nebulizers are preferred in sicker hospitalized patients because they don't require coordination of 20+ inhalations needed to match nebulizer efficacy. 1

• Avoid intravenous methylxanthines (theophylline/aminophylline) entirely—they increase side effects without added benefit. 1

Systemic Corticosteroid Protocol

Give oral prednisone 30-40 mg once daily for exactly 5 days starting immediately. 1, 2, 3 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, 2

• Do not continue corticosteroids beyond 5-7 days after the acute episode unless there is a separate indication. 1
• Corticosteroids improve lung function, oxygenation, shorten recovery time, and reduce treatment failure by over 50%. 1, 3

Antibiotic Therapy Criteria

Prescribe antibiotics for 5-7 days when the patient has increased sputum purulence PLUS either increased dyspnea OR increased sputum volume. 1 This "cardinal symptom" approach identifies bacterial exacerbations requiring antibiotics. 1

First-line antibiotic choices include: 1

• Amoxicillin with clavulanic acid
• Doxycycline (tetracycline derivative)
• Macrolides (azithromycin)

The choice should be based on local bacterial resistance patterns, targeting the most common organisms: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1, 2

Oxygen Management for Hospitalized Patients

Target oxygen saturation of 88-92% using controlled oxygen delivery to prevent CO2 retention. 1, 3 Start conservatively with 28% FiO2 via Venturi mask or 2 L/min via nasal cannula. 3

• Obtain arterial blood gas within 60 minutes of initiating oxygen therapy to assess for worsening hypercapnia or acidosis. 1, 3

Respiratory Support for Severe Exacerbations

Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with: 1, 2, 3

• Acute hypercapnic respiratory failure (pH <7.26 with rising PaCO2)
• Persistent hypoxemia despite oxygen
• Severe dyspnea with respiratory muscle fatigue

NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospitalization duration, and improves survival. 1

Hospitalization Decision Algorithm

Hospitalize patients with any of the following: 1, 2, 3

• Marked increase in symptom intensity requiring nebulization
• Severe underlying COPD (FEV1 <50% predicted)
• New physical signs (cyanosis, peripheral edema, persistent rhonchi after initial treatment)
• Failure to respond to initial outpatient management
• Significant comorbidities (pneumonia, cardiac arrhythmia, heart failure)
• Acute respiratory failure indicators (confusion, inability to maintain adequate oxygenation)
• Older age with inability to care for self at home

More than 80% of exacerbations can be managed on an outpatient basis. 1

Outpatient Management Protocol

For mild-to-moderate exacerbations managed at home: 1, 2

• Short-acting bronchodilators via MDI with spacer or nebulizer
• Prednisone 30-40 mg orally once daily for 5 days
• Antibiotics for 5-7 days if cardinal symptoms present
• Schedule follow-up within 3-7 days to assess response

Post-Exacerbation Management

Schedule pulmonary rehabilitation within 3 weeks after hospital discharge—this reduces hospital readmissions and improves quality of life. 1, 2, 3 Do NOT initiate pulmonary rehabilitation during hospitalization, as this increases mortality. 1

Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or LAMA/LABA/ICS triple therapy) before hospital discharge. 1 Continue existing triple therapy unchanged during the acute exacerbation—do not step down from triple therapy during or immediately after exacerbation, as ICS withdrawal increases recurrent exacerbation risk. 1

Prevention Strategies for Frequent Exacerbators

For patients with ≥2 moderate-to-severe exacerbations per year despite optimal triple therapy (LAMA/LABA/ICS), consider adding: 1, 4

• Macrolide maintenance therapy (azithromycin 250-500 mg three times weekly) for former smokers with frequent exacerbations, though this requires monitoring for QT prolongation, hearing loss, and bacterial resistance 1
• Roflumilast (PDE-4 inhibitor) 500 mcg once daily for patients with severe COPD associated with chronic bronchitis and history of exacerbations—this reduces exacerbation rate by 15-18% 4
• N-acetylcysteine or other mucolytic agents for chronic bronchitic phenotype 1

Common Pitfalls to Avoid

• Never use theophylline in acute exacerbations—no benefit with increased side effects. 1
• Never extend corticosteroids beyond 5-7 days for a single exacerbation. 1
• Never delay NIV in patients with acute hypercapnic respiratory failure. 1
• Never use chest physiotherapy in acute COPD exacerbations—no evidence of benefit. 1, 2
• Never target oxygen saturation >92% in COPD patients—risk of worsening hypercapnia. 1, 3

Additional Supportive Measures for Hospitalized Patients

• Administer prophylactic subcutaneous heparin for venous thromboembolism prevention in patients with acute-on-chronic respiratory failure 1
• Use diuretics only if there is peripheral edema and raised jugular venous pressure 1, 2
• Obtain chest radiograph on all hospitalized patients to exclude pneumonia, pneumothorax, or pulmonary edema 1
• Perform ECG if heart rate <60 or >110 bpm, or if cardiac symptoms present 1