What is the treatment for a patient experiencing an emphysema exacerbation?

Treatment of Emphysema Exacerbation

Treat emphysema exacerbations with controlled oxygen therapy (targeting SaO₂ 88-93%), nebulized bronchodilators (albuterol 2.5-5 mg and ipratropium 0.5 mg every 20 minutes for 3 doses), and systemic corticosteroids (prednisolone 30-60 mg orally for 5-7 days without taper), plus antibiotics if sputum is purulent or mechanical ventilation is needed. 1

Immediate Assessment and Oxygen Therapy

• Measure arterial blood gases immediately noting the inspired oxygen concentration (FiO₂), as this is critical to guide therapy and avoid dangerous hypercapnia 1
• Target oxygen saturation of 88-93% using controlled delivery via Venturi mask at 28% FiO₂ or nasal cannulae at 2 L/min until arterial blood gases are known 1
• Recheck blood gases within 60 minutes of starting oxygen and within 60 minutes of any change in inspired oxygen concentration 1
• If pH remains above 7.26 and PaO₂ is responding, gradually increase inspired oxygen until PaO₂ exceeds 7.5 kPa (approximately 56 mmHg) 1
• A pH below 7.26 is predictive of poor outcome and signals need for escalation to noninvasive ventilation 1

Critical Pitfall: Avoid High-Flow Oxygen

The most dangerous error in emphysema exacerbations is administering uncontrolled high-flow oxygen, which can precipitate life-threatening hypercapnic respiratory failure. Always use controlled oxygen delivery until blood gases confirm it is safe to increase 1.

Bronchodilator Therapy

• Administer nebulized albuterol 2.5-5 mg (or terbutaline 5-10 mg) immediately upon arrival 1
• Add ipratropium bromide 0.25-0.5 mg to the nebulizer for moderate to severe exacerbations, as the combination reduces hospitalizations 1
• Repeat bronchodilators every 20 minutes for 3 doses, then continue at 4-6 hourly intervals 1
• Power nebulizers with compressed air (not oxygen) if PaCO₂ is elevated or respiratory acidosis is present, while continuing supplemental oxygen at 1-2 L/min via nasal prongs during nebulization 1
• There is no significant difference in outcomes between 2.5 mg and 5 mg doses of albuterol during exacerbations 2

Bronchodilator Delivery Method

Metered-dose inhalers with spacers are equally effective as nebulizers when properly administered, but nebulizers may be easier for severely breathless patients to use 1.

Systemic Corticosteroids

• Administer prednisolone 30-60 mg orally immediately (or IV hydrocortisone 100-200 mg if oral route not possible) 1
• Continue for 5-7 days without tapering - this modest dose and short course limits steroid exposure without sacrificing efficacy 1
• Systemic corticosteroids are recommended for moderate and severe exacerbations, as they improve multiple outcomes 1, 3

Antibiotic Therapy

• Prescribe antibiotics for 7-14 days when sputum becomes purulent or mechanical ventilation (invasive or noninvasive) is needed 1
• First-line choices: amoxicillin or tetracycline unless recently used with poor response 1
• Second-line alternatives: broad-spectrum cephalosporin or newer macrolides for more severe exacerbations or lack of response to first-line agents 1
• The most common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1

Antibiotic Selection Nuance

Knowledge of local resistance patterns is helpful in directing empirical therapy. Culture sputum in exacerbations to determine appropriate second choices when response to initial therapy is poor 1.

Noninvasive Ventilation

• Initiate noninvasive ventilation for hypercapnic respiratory failure from acute exacerbation - there is strong evidence of benefit 1
• Consider noninvasive ventilation when pH falls below 7.26 despite controlled oxygen therapy 1
• Evidence also supports benefit for patients who remain hypercapnic after hospital discharge from an exacerbation 1

Monitoring Protocol

• Measure arterial blood gases within 60 minutes of starting treatment and repeat if clinical situation deteriorates 1
• Record initial FEV₁ and/or peak flow and start a serial peak flow chart as soon as possible 1
• Obtain chest radiograph, full blood count, urea and electrolytes, and ECG within first 24 hours 1
• Oximetry monitoring may be satisfactory if initial blood gases show normal PaO₂ and pH, and patient remains stable 1

Therapies to Avoid

• Methylxanthines (theophylline/aminophylline) lack evidence of effectiveness in acute exacerbations and have significant side effects 1, 4
• If methylxanthines are used, blood levels must be measured daily and continuous infusion (aminophylline 0.5 mg/kg per hour) should only be considered for non-responders 1
• Mucolytic agents and chest physiotherapy have no role in acute exacerbation management 3
• Antitussives lack data regarding benefit in COPD 1

Special Consideration: Alpha-1 Antitrypsin Deficiency

• Intravenous augmentation therapy may be considered in patients with documented alpha-1 antitrypsin deficiency and progressive emphysema 1

Hospital Admission Criteria

• Life-threatening features (silent chest, cyanosis, feeble respiratory effort, altered mental status)
• pH below 7.26 despite initial treatment
• Inadequate response to initial bronchodilator therapy
• Inability to manage at home due to social circumstances 1