How to manage a chronic obstructive pulmonary disease (COPD) exacerbation in a patient?

Management of COPD Exacerbation

For acute COPD exacerbations, immediately initiate combined short-acting bronchodilators (salbutamol 2.5-5 mg plus ipratropium 0.25-0.5 mg via nebulizer every 4-6 hours), oral prednisone 30-40 mg daily for exactly 5 days, and antibiotics for 5-7 days only if the patient has increased sputum purulence plus either increased dyspnea or increased sputum volume. 1

Initial Assessment and Triage

Determine severity to guide treatment setting:

• Mild exacerbations (manageable with bronchodilators alone) can be treated at home 1
• Moderate exacerbations (requiring bronchodilators plus systemic corticosteroids and/or antibiotics) may be managed outpatient 1
• Severe exacerbations require emergency department evaluation or hospitalization if any of the following are present: 1, 2
  • Use of accessory respiratory muscles or paradoxical chest wall movements 2
  • Loss of alertness or confusion 3
  • Cyanosis, new/worsening peripheral edema, or hemodynamic instability 2
  • Failure to respond to initial outpatient management 1
  • Severe underlying COPD with significant comorbidities 1

Pharmacological Management

1. Bronchodilator Therapy (First-Line)

Administer combined short-acting bronchodilators immediately upon presentation: 1

• Salbutamol (albuterol) 2.5-5 mg PLUS ipratropium bromide 0.25-0.5 mg via nebulizer 1
• This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 1
• Repeat dosing every 4-6 hours during the acute phase (typically 24-48 hours) until clinical improvement 1
• Nebulizers are preferred over metered-dose inhalers in sicker hospitalized patients because they are easier to use and don't require coordination 1
• Do NOT use intravenous methylxanthines (theophylline/aminophylline) - they increase side effects without added benefit 1

2. Systemic Corticosteroids (Mandatory)

Prednisone 30-40 mg orally once daily for exactly 5 days starting immediately: 1, 2

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1
• This improves lung function, oxygenation, shortens recovery time, and reduces treatment failure by over 50% 1
• A 5-day course is equally effective as 14-day courses but reduces cumulative steroid exposure by over 50% 1
• Do NOT continue corticosteroids beyond 5-7 days after the acute episode unless there is a separate indication 1

3. Antibiotic Therapy (Specific Criteria)

Prescribe antibiotics for 5-7 days ONLY when the patient has: 1, 2

• Increased sputum purulence PLUS either increased dyspnea OR increased sputum volume 1
• Alternatively, prescribe if all three cardinal symptoms are present (increased dyspnea, increased sputum volume, increased sputum purulence) 1

First-line antibiotic choices based on local resistance patterns: 1

• Amoxicillin/clavulanic acid 1
• Amoxicillin 1
• Doxycycline (tetracycline derivative) 1
• Macrolides (azithromycin) as alternative 1

The most common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1

Hospital Management for Severe Exacerbations

Controlled Oxygen Therapy

Target oxygen saturation of 88-92% using controlled oxygen delivery: 1

• Start with ≤2 L/min via nasal cannula 2
• Mandatory arterial blood gas measurement within 60 minutes of initiating oxygen to assess for worsening hypercapnia or acidosis 1, 2
• Avoid higher oxygen concentrations that can worsen hypercapnic respiratory failure 1

Noninvasive Ventilation (NIV)

Initiate NIV immediately as first-line therapy for patients with: 1, 2

• Acute hypercapnic respiratory failure 1
• Persistent hypoxemia despite oxygen 1
• Severe dyspnea with respiratory muscle fatigue 1
• pH <7.26 with rising PaCO₂ 2

NIV improves gas exchange, reduces work of breathing, decreases intubation rates by 80-85%, 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

Additional Supportive Measures

• Administer prophylactic subcutaneous heparin for venous thromboembolism prevention in patients with acute respiratory failure 1
• Use diuretics only if there is peripheral edema AND elevated jugular venous pressure 1
• Do NOT use chest physiotherapy - no evidence of benefit in acute COPD exacerbations 1
• Monitor fluid balance and nutrition status 1

Diagnostic Testing for Hospitalized Patients

• Obtain chest radiograph on all hospitalized patients to exclude pneumonia, pneumothorax, or pulmonary edema (changes management in 7-21% of cases) 1
• Perform ECG if resting heart rate <60/min or >110/min, or if cardiac symptoms are present 1

Discharge Planning and Follow-Up

Before discharge: 1

• Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) as soon as possible 1
• Do NOT step down from triple therapy during or immediately after exacerbation, as ICS withdrawal increases recurrent exacerbation risk 1
• Continue existing maintenance therapy unchanged during the acute exacerbation 1

Post-discharge: 1

• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life 1
• Do NOT initiate pulmonary rehabilitation during hospitalization - this increases mortality 1
• Schedule follow-up within 3-7 days to assess response 1
• Provide intensive smoking cessation counseling at every visit for current smokers 1
• Review inhaler technique to ensure proper use 1

Prevention of Future Exacerbations

For patients with ≥2 moderate-to-severe exacerbations per year despite optimal inhaled therapy: 1

• Consider adding long-term macrolide therapy (azithromycin 250-500 mg three times weekly), though this requires consideration of potential QT prolongation, hearing loss, and bacterial resistance 1
• Consider roflumilast (PDE-4 inhibitor) for patients with chronic bronchitic phenotype (chronic cough and sputum production) 1

Common pitfalls to avoid: 1

• Using systemic corticosteroids beyond 5-7 days for a single exacerbation
• Using theophylline in acute exacerbations due to side effect profile
• Delaying NIV in patients with acute hypercapnic respiratory failure
• Starting pulmonary rehabilitation during hospitalization rather than post-discharge
• Stepping down from triple therapy during or immediately after an exacerbation