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

Treatment of COPD Exacerbation

For acute COPD exacerbations, immediately initiate short-acting bronchodilators (beta-agonists with anticholinergics), systemic corticosteroids (prednisone 30-40 mg daily for exactly 5 days), and antibiotics when indicated by increased sputum purulence plus either increased dyspnea or sputum volume. 1

Immediate Bronchodilator Therapy

Administer combined short-acting beta-2 agonists (salbutamol 2.5-5 mg) 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. 2, 1

• Nebulizers are preferred for sicker hospitalized patients who cannot coordinate the 20+ inhalations required with MDI to match nebulizer efficacy. 1
• Continue repeat dosing every 4-6 hours for 24-48 hours until clinical improvement occurs. 1
• Do NOT use intravenous methylxanthines (theophylline/aminophylline) as they increase side effects without added benefit. 1, 3

Systemic Corticosteroid Protocol

Give oral prednisone 30-40 mg once daily for exactly 5 days starting immediately. 1, 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. 2, 1
• Corticosteroids improve lung function, oxygenation, shorten recovery time, and reduce treatment failure by over 50%. 1, 3
• Do not continue corticosteroids beyond 5-7 days after the acute episode unless there is a separate indication. 1

Antibiotic Therapy

Prescribe antibiotics for 5-7 days when 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). 1, 3

• First-line antibiotics include amoxicillin/clavulanate, amoxicillin, or tetracycline derivatives (doxycycline). 1, 3
• Alternative treatments include macrolides (azithromycin, clarithromycin) or respiratory fluoroquinolones (levofloxacin, moxifloxacin) based on local bacterial resistance patterns. 2, 1
• The most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1, 3
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44%. 1

Oxygen Therapy and Monitoring

Target oxygen saturation of 88-92% using controlled oxygen delivery (nasal cannula or Venturi mask). 1, 3

• Start with low-flow oxygen (≤28% FiO2 via Venturi mask or ≤2 L/min via nasal cannula) until arterial blood gas results are available in patients over 50 years with COPD history. 3
• Obtain arterial blood gas within 60 minutes of initiating oxygen therapy to assess for worsening hypercapnia or acidosis. 1, 3
• The goal is PaO2 ≥60 mmHg (8 kPa) without causing pH to drop below 7.26 due to CO2 retention. 3
• A pH below 7.26 is predictive of poor prognosis and indicates need for ventilatory support. 3

Respiratory Support for Severe Exacerbations

For patients with acute hypercapnic respiratory failure (pH <7.35 with elevated PaCO2), persistent hypoxemia despite oxygen, or severe dyspnea with respiratory muscle fatigue, initiate noninvasive ventilation (NIV) immediately as first-line therapy. 1, 3

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospitalization duration, and improves survival. 1, 3
• Contraindications to NIV include impaired consciousness, large volumes of secretions, facial trauma, or hemodynamic instability. 1
• Consider invasive mechanical ventilation if NIV fails, particularly in patients with a first episode of respiratory failure or demonstrable remedial cause. 1

Hospitalization Criteria

Hospitalize patients with marked increase in symptom intensity requiring nebulization, severe underlying COPD, new physical signs (cyanosis, peripheral edema, confusion), failure to respond to initial outpatient management, significant comorbidities, frequent exacerbations, new arrhythmias, or inability to care for self at home. 1, 3

• More than 80% of exacerbations can be managed on an outpatient basis. 1
• Severe exacerbations with acute respiratory failure require emergency department evaluation or hospitalization. 1

Diagnostic Testing for Hospitalized Patients

Obtain chest radiograph on all hospitalized patients to exclude pneumonia, pneumothorax, or pulmonary edema, as chest X-ray 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
• Send purulent sputum for culture and obtain blood cultures if pneumonia is suspected. 3
• Check full blood count, urea, electrolytes, and arterial blood gases. 3

Discharge Planning and Follow-Up

Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) before hospital discharge. 1

• Do not step down from triple therapy (LAMA/LABA/ICS) during or immediately after an 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, 3
• 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. 1
• At 8 weeks after an exacerbation, 20% of patients have not recovered to their pre-exacerbation state, highlighting the importance of follow-up care. 1

Additional Supportive Measures

• Use diuretics only if there is peripheral edema and raised jugular venous pressure. 1
• 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, as there is no evidence of benefit. 1
• Ensure the patient rinses mouth with water after inhaled corticosteroid use to reduce risk of oropharyngeal candidiasis. 4

Prevention of Future Exacerbations

For patients with ≥2 moderate-to-severe exacerbations per year despite optimal triple therapy (LAMA/LABA/ICS), consider adding long-term macrolide therapy (azithromycin 250-500 mg three times weekly). 1

• Macrolide therapy requires consideration of potential QT prolongation, hearing loss, and bacterial resistance. 1
• Consider roflumilast (PDE-4 inhibitor) for patients with moderate-to-severe COPD with chronic bronchitis phenotype (chronic cough and sputum production) and exacerbation history. 1
• Ensure annual influenza vaccination and pneumococcal vaccination as indicated. 3