What is the first-line treatment for a patient with a history of asthma or COPD experiencing an exacerbation?

First-Line Treatment for Asthma or COPD Exacerbation

For patients experiencing an acute exacerbation of asthma or COPD, immediately administer short-acting β2-agonists (such as albuterol/salbutamol 2.5-5 mg) combined with short-acting anticholinergics (such as ipratropium bromide 0.25-0.5 mg) via nebulizer or metered-dose inhaler, repeated every 4-6 hours, plus oral corticosteroids (prednisone 30-40 mg daily for exactly 5 days). 1, 2, 3

Immediate Bronchodilator Therapy

The combination approach is superior to monotherapy:

• Administer salbutamol 2.5-5 mg plus ipratropium bromide 0.25-0.5 mg together via nebulizer as the initial treatment 1, 2, 3
• This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 1, 3
• Repeat dosing every 4-6 hours during the acute phase (typically 24-48 hours) until clinical improvement occurs 1
• Either nebulizers or metered-dose inhalers with spacers can be used effectively, though nebulizers are preferred for sicker patients who cannot coordinate multiple inhalations 1, 2

Critical distinction for asthma versus COPD:

• For asthma exacerbations, the British Thoracic Society recommends salbutamol 5 mg or terbutaline 10 mg, repeated 4-6 hourly if improving, with ipratropium bromide 500 µg added if not responding 4
• For COPD exacerbations, the American Thoracic Society recommends the combination of short-acting β2-agonists with short-acting anticholinergics as initial therapy rather than sequential addition 1, 2, 3

Systemic Corticosteroid Protocol

Initiate corticosteroids immediately upon presentation:

• Prednisone 30-40 mg orally once daily for exactly 5 days is the evidence-based standard 1, 2, 3
• This regimen improves lung function, oxygenation, shortens recovery time, and reduces hospitalization duration 1, 2, 3
• A 5-day course is equally effective as 14-day courses but reduces cumulative steroid exposure by over 50% 1, 3
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1, 2
• Do not extend corticosteroids beyond 5-7 days for a single exacerbation unless there is a separate indication 1
• Prednisolone is FDA-approved for acute exacerbations of COPD 5

Oxygen Therapy (When Indicated)

For patients with hypoxemia:

• Target oxygen saturation of 88-92% (or PaO2 ≥60 mmHg) using controlled oxygen delivery to avoid CO2 retention in COPD patients 1, 2, 3
• In patients with known COPD aged 50 years or older, initial FiO2 should not exceed 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known 2, 3
• Mandatory arterial blood gas measurement within 60 minutes of initiating oxygen therapy to assess for worsening hypercapnia or acidosis 1, 2
• For acute severe asthma, patients need additional oxygen with nebulizers running at 6-8 L/min flow rate 4

Antibiotic Therapy (Selective Use)

Antibiotics are indicated only when specific criteria are met:

• Prescribe antibiotics for 5-7 days when the patient has increased sputum purulence plus either increased dyspnea OR increased sputum volume 1, 2, 3
• First-line choices: amoxicillin, tetracycline derivatives (doxycycline), or amoxicillin/clavulanic acid based on local bacterial resistance patterns 1, 2, 3
• Alternative treatments include newer cephalosporins, macrolides (azithromycin), or quinolone antibiotics 1, 3
• The most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1

Severity Assessment and Treatment Setting

Determine appropriate treatment location based on severity:

• Mild exacerbations: Treat outpatient with short-acting bronchodilators only 1, 3
• Moderate exacerbations: Treat outpatient with short-acting 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 intensity, inability to eat or sleep due to symptoms, worsening hypoxemia/hypercapnia, changes in mental status, or inability to care for oneself 1, 2, 3

For asthma, severity indicators requiring hospitalization include:

• Cannot complete sentences, respiratory rate >25/min, heart rate >110/min, peak expiratory flow <50% best 4
• For children: cannot talk or feed, respiratory rate >50/min, heart rate >140/min, peak expiratory flow <50% predicted 4

Respiratory Support for Severe Cases

When acute respiratory failure develops:

• Initiate noninvasive ventilation (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, 2, 3
• Consider invasive mechanical ventilation if NIV fails, particularly in patients with a first episode of respiratory failure or demonstrable remedial cause 1

Common Pitfalls to Avoid

Critical errors that worsen outcomes:

• Do NOT use intravenous methylxanthines (theophylline/aminophylline) - they increase side effects without added benefit 1, 2, 6
• Do NOT delay corticosteroids - early administration within the first hour impacts the need for ICU or hospital admission 7
• Do NOT use short-acting β2-agonists alone when combination therapy with anticholinergics is available, as monotherapy is less effective 4, 1
• Do NOT use chest physiotherapy in acute COPD exacerbations - there is no evidence of benefit 1
• Do NOT step down from triple maintenance therapy (LAMA/LABA/ICS) during or immediately after an exacerbation, as ICS withdrawal increases recurrent exacerbation risk 1, 3

Discharge Planning

Before discharge from hospital or emergency department:

• Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) as soon as possible 1, 3
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life 1, 3
• Provide intensive smoking cessation counseling with nicotine replacement therapy and behavioral intervention for current smokers 1
• Review and correct inhaler technique at every visit 1
• Schedule follow-up within 3-7 days to assess response 1