What is the best standard treatment in the hospital for a patient with chronic obstructive pulmonary disease (COPD) exacerbation, likely with a history of smoking and pre-existing lung disease?

Hospital Management of COPD Exacerbation

For hospitalized COPD exacerbation patients, immediately initiate combined short-acting β2-agonists (salbutamol 2.5-5 mg) plus short-acting anticholinergics (ipratropium 0.25-0.5 mg) via nebulizer every 4-6 hours, oral prednisone 30-40 mg daily for exactly 5 days, controlled oxygen targeting SpO2 88-92%, and antibiotics for 5-7 days if two or more cardinal symptoms are present (increased dyspnea, sputum volume, or purulence). 1

Immediate Assessment and Oxygen Management

Upon hospital arrival, perform pulse oximetry immediately and obtain arterial blood gases if SpO2 <90% or respiratory acidosis is suspected. 1 Target oxygen saturation of 88-92% using controlled oxygen delivery—higher oxygen concentrations worsen hypercapnic respiratory failure and increase mortality in COPD patients. 1, 2 Mandatory repeat arterial blood gas measurement within 60 minutes of initiating oxygen therapy is essential to assess for worsening hypercapnia or acidosis. 1, 2

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 Perform ECG if resting heart rate <60/min or >110/min, or if cardiac symptoms are present. 2, 1

Bronchodilator Therapy

Combined short-acting β2-agonists and anticholinergics provide superior bronchodilation lasting 4-6 hours compared to either agent alone. 1, 2 Administer salbutamol (albuterol) 2.5-5 mg plus ipratropium bromide 0.25-0.5 mg via nebulizer every 4-6 hours during the acute phase until clinical improvement occurs, typically 24-48 hours. 1 Nebulizers are preferred over metered-dose inhalers in sicker hospitalized patients because they are easier to use and don't require coordination of 20+ inhalations needed to match nebulizer efficacy. 1

Do NOT use intravenous methylxanthines (theophylline/aminophylline)—they increase side effects without added benefit. 1, 3

Systemic Corticosteroid Protocol

Administer oral prednisone 30-40 mg once daily for exactly 5 days starting immediately upon admission. 1, 4 This improves lung function, oxygenation, shortens recovery time, and reduces treatment failure 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, 4 Do not continue corticosteroids beyond 5-7 days after the acute episode unless there is a separate indication for long-term treatment. 1 A 5-day course is equally effective as 14-day courses but reduces cumulative steroid exposure by over 50%. 1

Corticosteroids may be less efficacious in patients with lower blood eosinophil levels. 1

Antibiotic Therapy

Prescribe antibiotics for 5-7 days only when the patient has at least two of the following cardinal symptoms: increased dyspnea, increased sputum volume, or increased sputum purulence. 1, 4 Antibiotics reduce the risk of short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44%. 1

First-line antibiotic choices include amoxicillin/clavulanate, amoxicillin, or tetracycline (doxycycline), with macrolides (azithromycin) as alternative. 1, 4 The most common organisms causing COPD exacerbations are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1, 4 Antibiotic choice should be based on local bacterial resistance patterns. 1

Respiratory Support for Severe Exacerbations

For patients with acute hypercapnic respiratory failure (pH <7.35 with hypercapnia), persistent hypoxemia despite oxygen, or severe dyspnea with respiratory muscle fatigue, initiate noninvasive ventilation (NIV) immediately as first-line therapy. 2, 1, 4 NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospitalization duration, and improves survival. 2, 1, 5

If pH is <7.35 in the presence of hypercapnia, NIV should be delivered in a controlled environment such as intermediate ICUs and/or high-dependency units. 2 If pH is <7.25, NIV should be administered in the ICU with intubation readily available. 2 The combination of CPAP (4-8 cmH2O) plus pressure support ventilation (10-15 cmH2O) provides the most effective mode of NIV. 2

Confused patients and those with large volumes of secretions are less likely to respond well to NIV. 1 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. 1

Additional Supportive Measures

Use diuretics only if there is peripheral edema and raised jugular venous pressure. 1, 4 Administer prophylactic subcutaneous heparin for venous thromboembolism prevention in patients with acute-on-chronic respiratory failure. 1 Do NOT use chest physiotherapy in acute COPD exacerbations—there is no evidence of benefit. 1, 4

Monitor fluid balance and nutrition status throughout hospitalization. 1

Discharge Planning and Follow-Up

Continue or initiate maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combinations) before hospital discharge. 1, 4 Patients should not step down from triple therapy during or immediately after exacerbation, as ICS withdrawal increases recurrent exacerbation risk. 1

Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 1, 4 Do not initiate pulmonary rehabilitation during hospitalization, as this increases mortality. 1 Schedule follow-up visit within 4 weeks to evaluate improvement in symptoms, assess need for supplemental oxygen, and ensure understanding of treatment regimen. 2

Provide intensive smoking cessation counseling with nicotine replacement therapy and behavioral intervention at every visit for current smokers. 1 Review inhaler technique to ensure proper use and adherence. 1

Common Pitfalls to Avoid

• Never target SpO2 >92% in COPD patients—excessive oxygen worsens V/Q mismatch and hypercapnia. 6, 1
• Never delay arterial blood gas measurement after initiating oxygen therapy—recheck at 30-60 minutes to recognize worsening acidosis. 6, 1
• Never use systemic corticosteroids beyond 5-7 days for a single exacerbation. 1
• Never delay NIV in patients with acute hypercapnic respiratory failure. 1
• Never use theophylline in acute exacerbations due to its side effect profile without added benefit. 1, 3