What medications are typically given to a patient experiencing a Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

Medications for COPD Exacerbation

For a COPD exacerbation, immediately start short-acting bronchodilators (albuterol with ipratropium), oral prednisone 30-40 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

Bronchodilator Therapy

Initiate combination short-acting β2-agonists (SABA) with short-acting anticholinergics (SAMA) immediately upon presentation. 1

• Administer albuterol 2.5-5 mg plus ipratropium bromide 0.25-0.5 mg via nebulizer or metered-dose inhaler with spacer 1
• Nebulizers are preferred over metered-dose inhalers in sicker hospitalized patients because they are easier to use and don't require coordination of 20+ inhalations needed to match nebulizer efficacy 1
• Repeat dosing every 4-6 hours during the acute phase (typically 24-48 hours) until clinical improvement occurs 1
• The combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 1

Do NOT use intravenous methylxanthines (theophylline or aminophylline) due to increased side effect profiles without added benefit. 1

Systemic Corticosteroids

Administer oral prednisone 30-40 mg once daily for exactly 5 days starting immediately. 1, 2

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1, 2
• A 5-day course is as effective as 14-day courses but reduces cumulative steroid exposure by over 50% 1, 2
• If oral administration is not possible due to vomiting or inability to swallow, use IV hydrocortisone 100 mg or IV methylprednisolone 1, 2
• Corticosteroids reduce treatment failure by over 50%, shorten recovery time, improve lung function and oxygenation, and reduce hospitalization duration 1, 2, 3
• Do NOT extend treatment beyond 5-7 days, as this increases adverse effects without additional clinical benefit 1, 2

Corticosteroid Benefits and Risks

• Corticosteroids prevent hospitalization for subsequent exacerbations within the first 30 days following the initial event 2
• Blood eosinophil count ≥2% predicts better response to corticosteroids, but current guidelines recommend treating all COPD exacerbations requiring emergent care regardless of eosinophil levels 2
• Common adverse effects include hyperglycemia (odds ratio 4.95), weight gain, and insomnia 2, 3
• Never use systemic corticosteroids long-term for exacerbation prevention beyond 30 days, as risks far outweigh any benefits 2

Antibiotic Therapy

Prescribe antibiotics for 5-7 days when the patient has increased sputum purulence PLUS either increased dyspnea OR increased sputum volume. 1

• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1
• First-line antibiotic choices include amoxicillin/clavulanic acid, amoxicillin, tetracycline derivatives (doxycycline), or macrolides (azithromycin) based on local bacterial resistance patterns 1
• Alternative treatments include newer cephalosporins or quinolone antibiotics 1
• The most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses 1

Oxygen and Respiratory Support

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

• Obtain mandatory arterial blood gas measurement within 1 hour of initiating oxygen to assess for worsening hypercapnia 1
• For patients with acute hypercapnic respiratory failure, initiate noninvasive ventilation (NIV) immediately as first-line therapy 1
• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospitalization duration, and improves survival 1

Severity-Based Treatment Algorithm

Mild Exacerbations (Outpatient)

• Short-acting bronchodilators only 1
• More than 80% of exacerbations can be managed on an outpatient basis 1

Moderate Exacerbations (Outpatient or Emergency Department)

• Short-acting bronchodilators plus antibiotics and/or oral corticosteroids 1
• Schedule follow-up within 3-7 days to assess response 1

Severe Exacerbations (Hospitalization Required)

• All of the above medications 1
• Consider hospitalization for marked increase in symptom intensity, severe underlying COPD, new physical signs, failure to respond to initial outpatient management, significant comorbidities, frequent exacerbations, new arrhythmias, diagnostic uncertainty, older age, or inability to care for self at home 1
• May require NIV or invasive mechanical ventilation 1

Critical Pitfalls to Avoid

• Never extend corticosteroid treatment beyond 5-7 days for a single exacerbation 1, 2
• Never use theophylline in acute exacerbations due to side effect profile without added benefit 1
• Never delay NIV in patients with acute hypercapnic respiratory failure 1
• Never use systemic corticosteroids long-term for exacerbation prevention beyond the first 30 days 2
• Do not use chest physiotherapy in acute exacerbations, as there is no evidence of benefit 1

Discharge Planning

• Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) before hospital discharge 1
• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life 1
• Do NOT initiate pulmonary rehabilitation during hospitalization, as this increases mortality 1
• Provide smoking cessation counseling at every visit 1
• Review inhaler technique to ensure proper use and adherence 1