What is the current recommendation for managing an adult patient with Acute Exacerbation of Chronic Bronchitis (AECB) and a history of Chronic Obstructive Pulmonary Disease (COPD) or chronic bronchitis, including the use of steroids, antibiotics, and other treatments?

Management of Acute Exacerbation of Chronic Bronchitis (AECB)

For patients with AECB, immediately initiate short-acting bronchodilators (beta-agonists with anticholinergics), administer oral prednisone 30-40 mg daily for exactly 5 days, and prescribe antibiotics for 5-7 days if the patient has increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2

Immediate Bronchodilator Therapy

Administer salbutamol (albuterol) 2.5-5 mg plus ipratropium bromide 0.25-0.5 mg via nebulizer immediately upon presentation, with repeat dosing every 4-6 hours during the acute phase until clinical improvement occurs (typically 24-48 hours). 1, 2 This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone. 3, 1

• For outpatient management, metered-dose inhalers with spacer are equally effective as nebulizers, but nebulizers are preferred for severely ill hospitalized patients who cannot coordinate multiple inhalations. 1, 2
• Do NOT use theophylline or aminophylline during acute exacerbations—these agents increase side effects without added benefit. 3, 1

Systemic Corticosteroid Protocol

Give oral prednisone 30-40 mg once daily for exactly 5 days starting immediately. 1, 2 This duration is equally effective as 8-14 week courses but reduces cumulative steroid exposure by over 50%. 3, 1

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake. 1, 2
• Corticosteroids improve lung function, oxygenation, shorten recovery time, reduce treatment failure by over 50%, and prevent hospitalization for subsequent exacerbations within the first 30 days. 3, 1, 2
• Do NOT continue corticosteroids beyond 5-7 days after the acute episode unless there is a separate indication for long-term treatment. 1

Antibiotic Therapy Criteria and Selection

Prescribe antibiotics for 5-7 days if the patient has increased sputum purulence PLUS either increased dyspnea OR increased sputum volume (at least 2 of 3 cardinal symptoms with purulence being one of them). 3, 1, 2

First-Line Antibiotic Choices (based on local resistance patterns):

• Amoxicillin/clavulanate (high-dose) 1, 2
• Doxycycline 1, 2
• Azithromycin or other macrolides 1, 2, 4

For Patients with Risk Factors (use respiratory fluoroquinolones):

Risk factors include: age ≥65 years, FEV1 <50% predicted, ≥4 exacerbations in 12 months, or significant comorbidities. 5, 6, 7

• Levofloxacin, moxifloxacin, or gemifloxacin are recommended as first-line therapy for complicated chronic bronchitis. 5, 7
• Fluoroquinolones provide better long-term outcomes than macrolides and have superior activity against resistant pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 5, 8, 7

Antibiotic Efficacy:

Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% when appropriately indicated. 1, 2

Oxygen Management for Hospitalized Patients

Target oxygen saturation of 88-92% (SpO2 ≥90%) using controlled oxygen delivery. 1, 2 Higher oxygen concentrations can worsen hypercapnic respiratory failure and increase mortality in COPD patients. 1

• Obtain arterial blood gas within 60 minutes of initiating oxygen therapy to assess for worsening hypercapnia or acidosis. 1, 2
• Drive nebulizers with compressed air (not oxygen) if PaCO2 is elevated and/or there is respiratory acidosis, continuing oxygen via nasal prongs at 1-2 L/min during nebulization. 2

Respiratory Support for Severe Exacerbations

Initiate noninvasive ventilation (NIV) immediately as first-line therapy if pH <7.26 with rising PaCO2 despite supportive treatment, acute hypercapnic respiratory failure, persistent hypoxemia despite oxygen, or severe dyspnea with respiratory muscle fatigue. 1, 2

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

Indications for Hospitalization

Hospitalize patients with: 1, 2

• Marked increase in symptom intensity requiring nebulization
• Severe underlying COPD (FEV1 <50% predicted)
• New physical signs (cyanosis, peripheral edema, altered mental status)
• Failure to respond to initial outpatient management within 24-48 hours
• Significant comorbidities (cardiac disease, diabetes)
• Frequent exacerbations (≥4 per year)
• New arrhythmias
• Older age (≥65 years) or inability to care for self at home
• Acute respiratory failure indicators (pH <7.26, rising PaCO2, inability to maintain adequate oxygenation)

Additional Supportive Measures

• Use diuretics ONLY if there is peripheral edema AND raised jugular venous pressure. 1, 2
• Administer prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure to prevent venous thromboembolism. 1, 2
• Do NOT use chest physiotherapy—there is no evidence of benefit in acute COPD exacerbations. 3, 1
• Do NOT use expectorants or mucolytic agents during acute exacerbations—they are not effective. 3

Discharge Planning and Post-Exacerbation Management

Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or LAMA/LABA/ICS triple therapy) before hospital discharge. 1, 2 Continue existing triple therapy unchanged during and after the acute exacerbation—do not step down therapy, 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, 2 Do NOT initiate pulmonary rehabilitation during hospitalization, as this increases mortality. 1

Provide intensive smoking cessation counseling with nicotine replacement therapy and behavioral intervention at every visit for current smokers. 3, 1, 2

Common Pitfalls to Avoid

• Never use theophylline/aminophylline in acute exacerbations due to increased side effects without benefit. 3, 1
• Never continue systemic corticosteroids beyond 5-7 days for a single exacerbation. 3, 1
• Never prescribe antibiotics for patients without increased sputum purulence unless they have all three cardinal symptoms. 3, 1, 2
• Never target oxygen saturation >92% in COPD patients, as this can worsen hypercapnia. 1, 2
• Never delay NIV in patients with acute hypercapnic respiratory failure (pH <7.26). 1, 2
• Never step down from triple therapy during or immediately after an exacerbation. 1

Follow-Up Care

Schedule follow-up within 3-7 days to assess response to treatment, as 20% of patients have not recovered to their pre-exacerbation state at 8 weeks. 1, 2 Review inhaler technique at every visit to ensure proper use and adherence. 1, 2