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

Treatment of COPD Exacerbations

For a patient experiencing a COPD flare, immediately initiate triple therapy: systemic corticosteroids (40 mg prednisone daily for 5 days), increased bronchodilator therapy with short-acting agents (or nebulizers if inhaler technique is inadequate), and antibiotics when ≥2 cardinal symptoms are present (increased breathlessness, increased sputum volume, or purulent sputum). 1

Immediate Pharmacological Management

Systemic Corticosteroids

• Administer 30-40 mg prednisone daily for 5-7 days to improve lung function and shorten recovery time during acute exacerbations. 1
• This short course (5 days at 40 mg) is supported by the American College of Chest Physicians and improves outcomes without requiring prolonged tapering. 1

Bronchodilator Therapy

• Increase bronchodilator therapy immediately, using short-acting β2-agonists and/or anticholinergics. 1
• Consider nebulizers if the patient's inhaler technique is inadequate during the acute phase, as respiratory distress may impair proper inhaler use. 1
• Note the FDA warning: ipratropium as a single agent has not been adequately studied for acute COPD exacerbations, and drugs with faster onset (β2-agonists) may be preferable as initial therapy. 2
• Combination therapy with both β2-agonists and anticholinergics can be used, though evidence shows it may not be more effective than either drug alone in reversing acute bronchospasm. 2

Antibiotic Therapy

• Prescribe antibiotics when ≥2 of the following cardinal symptoms are present: increased breathlessness, increased sputum volume, or purulent sputum. 1
• Use a 7-14 day course when sputum becomes purulent, as recommended by the European Respiratory Society. 1
• Antibiotics are particularly justified in patients with severe airflow limitation who have febrile tracheobronchitis. 3

Critical Pitfalls to Avoid

• Do not use prophylactic antibiotics continuously or intermittently in COPD patients—there is no evidence supporting this practice. 1, 4
• Avoid beta-blocking agents (including eyedrop formulations) in all COPD patients during and after exacerbations. 1, 4
• Theophylline provides little additional benefit in patients receiving frequent inhaled bronchodilators and adequate corticosteroid dosing, and should not be routinely added. 3

Oxygen and Ventilatory Support

• Provide supplemental oxygen to maintain SpO2 ≥90% during rest, sleep, and exertion. 1
• Consider non-invasive ventilatory support for patients with severe nocturnal hypoxemia or respiratory muscle weakness. 1
• Oxygen concentrators are the easiest mode of treatment for home use. 1

Post-Exacerbation Management

Discharge Planning

• Reassess and optimize inhaler technique before discharge, as 76% of COPD patients make important errors with metered-dose inhalers. 1
• Ensure patients are on appropriate maintenance therapy: LABA/LAMA combination for severe COPD with high exacerbation risk. 1
• Add ICS to LABA/LAMA only if FEV1 <50% predicted AND ≥2 exacerbations in the previous year, or blood eosinophil count ≥150-200 cells/µL. 1

Preventive Measures

• Strongly encourage smoking cessation at every clinical encounter—this is the single most important intervention. 1, 4
• Administer annual influenza vaccination to all COPD patients. 1, 4
• Consider pneumococcal vaccination with revaccination every 5-10 years. 1
• Refer to pulmonary rehabilitation programs, which improve exercise tolerance and quality of life. 1, 4

Common Adverse Effects to Monitor

When using ipratropium during exacerbations, monitor for headache, mouth dryness, and aggravation of COPD symptoms, which are more common at higher doses (≥2,000 mcg daily). 2 Watch for rare hypersensitivity reactions including urticaria, angioedema, bronchospasm, and acute eye pain. 2