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

Treatment for COPD Exacerbation

For acute COPD exacerbations, initiate treatment with short-acting bronchodilators (β2-agonists with or without anticholinergics), systemic corticosteroids (40 mg prednisone daily for 5 days), and antibiotics when sputum becomes purulent or when at least 2 cardinal symptoms are present (increased breathlessness, increased sputum volume, purulent sputum). 1, 2

Immediate Bronchodilator Therapy

• Short-acting inhaled β2-agonists (SABAs), with or without short-acting anticholinergics, are the initial bronchodilators recommended for acute treatment of exacerbations. 1
• Metered-dose inhalers (with or without spacer) deliver equivalent FEV1 improvements compared to nebulizers, though nebulizers may be easier for severely ill patients to use. 1
• Intravenous methylxanthines should be avoided due to increased side effects without additional benefit. 1

Systemic Corticosteroid Therapy

• Administer 40 mg prednisone orally daily for 5 days to shorten recovery time, improve FEV1 and oxygenation, reduce early relapse risk, and decrease hospitalization length. 1, 2, 3
• Oral prednisolone is equally effective to intravenous administration, making outpatient treatment feasible for most exacerbations. 1
• Duration should not exceed 5-7 days, as longer courses provide no additional benefit. 1, 2
• Corticosteroids may be less effective in patients with lower blood eosinophil levels, though prospective data are still needed. 1

Antibiotic Therapy

• Prescribe antibiotics when ≥2 of the following cardinal symptoms are present: increased breathlessness, increased sputum volume, or purulent sputum. 2, 3
• Evidence supports antibiotic use specifically when sputum purulence is present, with treatment duration of 5-7 days. 1, 2
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% when appropriately indicated. 1

Treatment Setting Determination

• More than 80% of exacerbations can be managed in the outpatient setting with the above pharmacologic regimen. 1
• Consider hospitalization for patients with severe underlying disease, inability to manage at home, inadequate response to initial treatment, or presence of acute respiratory failure. 1

Ventilatory Support

• Non-invasive ventilation (NIV) should be the first mode of ventilation for patients with acute respiratory failure and no absolute contraindications, as it improves gas exchange, reduces work of breathing, decreases intubation need, shortens hospitalization, and improves survival. 1

Common Pitfalls to Avoid

• Do not use methylxanthines during acute exacerbations due to their unfavorable side effect profile without proven benefit. 1
• Avoid extending corticosteroid therapy beyond 5-7 days, as this increases adverse effects without improving outcomes. 1, 2
• Do not prescribe antibiotics routinely for all exacerbations—reserve them for patients meeting the clinical criteria of purulent sputum or ≥2 cardinal symptoms. 1, 2
• Recognize that approximately 20% of patients have not recovered to their pre-exacerbation state at 8 weeks, requiring close follow-up. 1