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

Treatment of COPD Exacerbation

Immediately initiate combined short-acting bronchodilators (albuterol 2.5-5 mg plus ipratropium 0.25-0.5 mg via nebulizer every 4-6 hours), oral prednisone 40 mg daily for exactly 5 days, and antibiotics for 5-7 days if the patient has increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2, 3

Initial Assessment and Severity Classification

Classify the exacerbation severity to determine treatment setting 3:

• Mild exacerbations: Treat outpatient with short-acting bronchodilators only 1, 3
• Moderate exacerbations: Treat outpatient with bronchodilators plus antibiotics and/or oral corticosteroids 1, 3
• Severe exacerbations: Require hospitalization or emergency department evaluation, particularly with acute respiratory failure, marked increase in dyspnea, inability to eat or sleep due to symptoms, changes in mental status, or inability to care for oneself 1, 3

Bronchodilator Therapy

Administer albuterol (salbutamol) 2.5-5 mg combined with ipratropium 0.25-0.5 mg via nebulizer every 4-6 hours during the acute phase for the first 24-48 hours. 1, 2, 3 This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 1, 3.

• For patients who can coordinate inhalation technique, use albuterol 2 puffs (180 mcg) plus ipratropium 2 puffs (36 mcg) via metered-dose inhaler with spacer every 4-6 hours 2
• Nebulizers are preferred for sicker hospitalized patients who cannot coordinate the 20+ inhalations needed to match nebulizer efficacy 1
• Do NOT use intravenous methylxanthines (theophylline/aminophylline) as they increase side effects without added benefit 1, 4, 5

Systemic Corticosteroid Protocol

Administer prednisone 40 mg orally once daily for exactly 5 days starting immediately. 1, 2, 3 This regimen improves lung function, oxygenation, shortens recovery time, and reduces treatment failure by over 50% 1, 3.

• Alternative: prednisolone 30-40 mg orally once daily for 5 days 1, 2
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1
• Do NOT extend corticosteroids beyond 5-7 days as this increases adverse effects without additional benefit 1, 2
• Corticosteroids prevent recurrent exacerbations within the first 30 days but provide no benefit beyond this window 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 of them). 1, 2, 3

First-line antibiotic choices 1, 2, 3:

• Amoxicillin-clavulanate (preferred for broader coverage)
• Azithromycin (macrolide)
• Doxycycline (tetracycline derivative)

Alternative antibiotics include newer cephalosporins or quinolones for patients with risk factors for resistant organisms 1, 3. Base antibiotic choice on local bacterial resistance patterns, targeting the most common organisms: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1.

Oxygen Therapy and Respiratory Support

Target oxygen saturation of 88-92% using controlled oxygen delivery to avoid CO2 retention. 1, 2, 3

• Start with 28% Venturi mask or 2 L/min nasal cannula 2, 3
• Obtain arterial blood gas within 1 hour of initiating oxygen to assess for worsening hypercapnia or acidosis 1, 2
• Adjust FiO2 to maintain PaO2 ≥60 mmHg without causing CO2 retention 2, 3

Noninvasive Ventilation (NIV)

Initiate NIV immediately as first-line therapy for patients with acute hypercapnic respiratory failure, persistent hypoxemia despite oxygen, or severe dyspnea with respiratory muscle fatigue. 1, 2, 3

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50-65%, shortens hospitalization duration, and improves survival 1, 3
• Titrate NIV settings to achieve tidal volume 6-8 mL/kg and patient comfort 2
• Patients who are confused or have large volumes of secretions are less likely to respond well to NIV 1

Discharge Planning and Prevention

Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or triple therapy LAMA/LABA/ICS) before hospital discharge. 1, 3

• Do NOT step down from triple therapy during or immediately after an exacerbation as ICS withdrawal increases recurrent exacerbation risk 1, 3
• Verify inhaler technique at discharge 2
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life 1, 2, 3
• Do NOT initiate pulmonary rehabilitation during hospitalization as this increases mortality 1
• Provide intensive smoking cessation counseling with nicotine replacement therapy for current smokers 1

Additional Supportive Measures for Hospitalized Patients

• Monitor vital signs every 4 hours initially, with cardiac monitoring if arrhythmia is suspected 2
• Obtain chest radiograph on all hospitalized patients to exclude pneumonia, pneumothorax, or pulmonary edema 1
• Administer prophylactic subcutaneous heparin for venous thromboembolism prevention in patients with acute-on-chronic respiratory failure 1
• Do NOT use chest physiotherapy as there is no evidence of benefit in acute COPD exacerbations 1
• Use diuretics only if there is peripheral edema and raised jugular venous pressure 1

Common Pitfalls to Avoid

• Avoid extending corticosteroids beyond 5-7 days, which increases adverse effects without benefit 1, 2
• Do not use theophylline in acute exacerbations due to its side effect profile 1, 4
• Do not delay NIV in patients with acute hypercapnic respiratory failure 1
• Do not provide excessive oxygen (target 88-92%, not higher) as this can worsen hypercapnic respiratory failure 1, 3
• Do not prescribe antibiotics indiscriminately; require at least 2 cardinal symptoms with purulence being one of them 1, 2