What is the treatment for Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)?

From the Guidelines

Treatment for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) should include bronchodilators, systemic corticosteroids, and antibiotics when appropriate, as recommended by the most recent guidelines 1. The management of AECOPD involves a multifaceted approach to reduce symptoms, improve lung function, and prevent future exacerbations.

• Short-acting bronchodilators like albuterol (2.5-5 mg via nebulizer or 4-8 puffs via MDI every 4-6 hours) and ipratropium (0.5 mg via nebulizer or 4-8 puffs via MDI every 6-8 hours) are first-line treatments to relieve bronchospasm, as suggested by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report 1.
• Systemic corticosteroids, typically prednisone 40mg daily for 5 days, help reduce inflammation and speed recovery, with evidence showing improved lung function, oxygenation, and shortened recovery time and hospitalization duration 1.
• Antibiotics should be prescribed when there are signs of bacterial infection (increased sputum purulence, volume, or dyspnea); commonly used options include amoxicillin-clavulanate 875/125mg twice daily, doxycycline 100mg twice daily, or azithromycin 500mg on day 1 followed by 250mg daily for 4 days, as recommended by the American Academy of Family Physicians (AAFP) guideline 1.
• Supplemental oxygen should be provided to maintain oxygen saturation ≥88%, and for severe exacerbations, non-invasive ventilation (NIV) may be necessary, as recommended by the European Respiratory Society (ERS) and American Thoracic Society (ATS) guideline 1. After the acute phase, patients should receive maintenance therapy with long-acting bronchodilators, smoking cessation support, pulmonary rehabilitation referral, and vaccination against influenza and pneumococcal disease, to target the underlying pathophysiology of COPD exacerbations, which involves increased airway inflammation, mucus hypersecretion, and bronchoconstriction, often triggered by respiratory infections or environmental factors.

From the Research

AECOPD Treatment Overview

• AECOPD is a significant event that results in substantial morbidity and mortality, and its treatment is crucial for managing the disease.
• Systemic corticosteroids are a standard treatment for AECOPD, and they have been shown to improve airflow, decrease the rate of treatment failure and risk of relapse, and may improve symptoms and decrease the length of hospital stay 2.
• The optimal strategy for dosing and administration of corticosteroids in AECOPD is still debated, with some studies suggesting that low-dose oral corticosteroids are as efficacious as high-dose, intravenous corticosteroid regimens, while minimizing adverse effects 2, 3.

Corticosteroid Dosage and Duration

• The best available evidence suggests that higher-dose corticosteroids are not superior to treatment with lower-dose corticosteroids in patients with severe AECOPD 3.
• Recent studies suggest that shorter durations of corticosteroid therapy are as efficacious as the traditional treatment durations currently recommended by guidelines 2, 3.
• However, there is a paucity of data to support the selection of a systemic steroid dose in patients having an AECOPD, and randomized trials that measure patient-centered outcomes and compare doses of systemic steroids in patients having an AECOPD are needed 4.

Antibiotic Therapy

• Macrolides, fluoroquinolones, and beta-lactams are all reasonable treatment options for severe AECOPD, and the decision to use one over the other should be based upon patient characteristics and institutional or regional antimicrobial susceptibility patterns 3.
• Daily azithromycin has been shown to decrease AECOPD, particularly those requiring both antibiotic and steroid treatment, but its effectiveness may vary depending on patient characteristics, such as age and smoking status 5.

Provider Perceptions and Prescribing Habits

• Steroid overprescribing is well documented in AECOPD, and facilities should implement steroid stewardship efforts to minimize unwanted side effects 6.
• Provider perceptions and prescribing habits may vary, with some providers selecting higher doses or longer treatment durations than others, and education on the evidence behind using lower doses and oral agents may be necessary to improve guideline utilization 6.