What is the recommended management for an adult patient experiencing an acute chronic obstructive pulmonary disease exacerbation?

Management of Acute COPD Exacerbation

For an adult experiencing acute COPD exacerbation, immediately initiate short-acting bronchodilators (combined beta-agonist and anticholinergic), oral prednisone 40 mg daily for exactly 5 days, controlled oxygen targeting 88-92% saturation, and antibiotics if the patient has increased sputum purulence plus either increased dyspnea or sputum volume. 1

Initial Assessment and Severity Classification

Determine severity based on specific clinical parameters to guide treatment location:

• Mild exacerbations can be managed at home with short-acting bronchodilators alone 1
• Moderate exacerbations require bronchodilators plus antibiotics and/or oral corticosteroids, typically managed outpatient 1
• Severe exacerbations mandate hospitalization or emergency department evaluation, particularly with respiratory rate >30 breaths/min, loss of alertness, inability to eat/sleep due to symptoms, or new physical signs 2, 1

Document the presence of cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence, as this determines antibiotic indication 1

Immediate Pharmacological Management

Bronchodilator Therapy

Administer combined short-acting beta-agonist (albuterol 2.5-5 mg) plus short-acting anticholinergic (ipratropium 0.25-0.5 mg) via nebulizer every 4-6 hours during the acute phase. 1 This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 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

Do NOT use intravenous methylxanthines (theophylline/aminophylline) - they increase side effects without added benefit 1, 3

Systemic Corticosteroid Protocol

Administer oral prednisone 30-40 mg once daily for exactly 5 days starting immediately. 1, 3 This is the evidence-based standard supported by the European Respiratory Society and American Thoracic Society 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, 3. If oral administration is impossible due to vomiting or inability to swallow, use IV hydrocortisone 100 mg 3. However, IV corticosteroids are associated with longer hospital stays and higher costs without clear evidence of benefit over oral administration 3

Do not extend corticosteroid treatment beyond 5-7 days - this increases adverse effects (hyperglycemia, weight gain, insomnia) without providing additional clinical benefit 3

Patients with blood eosinophil count ≥2% show better response to corticosteroids (treatment failure rate 11% vs 66% with placebo), though current guidelines recommend treating all COPD exacerbations requiring emergent care regardless of eosinophil levels 3

Antibiotic Therapy

Prescribe antibiotics for 5-7 days if 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, or doxycycline, with macrolides (azithromycin) as alternatives 1. Antibiotic choice should be based on local bacterial resistance patterns 1. The most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1

Oxygen Management and Respiratory Support

Controlled Oxygen Therapy

Target oxygen saturation of 88-92% using controlled oxygen delivery (24-28% Venturi mask initially). 2, 1 Higher oxygen concentrations can worsen hypercapnic respiratory failure and increase mortality in COPD patients 1

Obtain arterial blood gas measurement within 60 minutes of initiating oxygen therapy to assess for worsening hypercapnia or acidosis 2, 1. If the patient is already on oxygen, recheck blood gases after 30-60 min or if there is evidence of clinical deterioration 2

If pH and PCO2 are normal after initial blood gas, aim for oxygen saturation of 94-98% unless there is history of previous hypercapnic respiratory failure requiring NIV or if the patient's usual oxygen saturation when stable is below 94% (these patients should maintain target range of 88-92%) 2

Noninvasive Ventilation (NIV)

Initiate NIV immediately as first-line therapy for patients with acute hypercapnic respiratory failure (PCO2 >6 kPa or 45 mmHg) and acidosis (pH <7.35) that persists for more than 30 minutes after initiation of standard medical management. 2, 1 NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospitalization duration, and improves survival 1

NIV is also indicated for persistent hypoxemia despite oxygen or severe dyspnea with respiratory muscle fatigue 1. Confused patients and those with large volumes of secretions are less likely to respond well to NIV 1

Consider invasive mechanical ventilation if NIV fails, particularly in patients with a first episode of respiratory failure, demonstrable remedial cause, or acceptable baseline quality of life 1

Hospital Management for Severe Exacerbations

Monitoring and Supportive Care

• Continue nebulized bronchodilators every 4-6 hours for 24-48 hours until clinical improvement occurs 1
• Monitor for respiratory failure indicators: worsening dyspnea despite treatment, confusion or altered mental status, pH <7.26 with rising PaCO2, and inability to maintain adequate oxygenation 1
• Obtain chest radiograph on all hospitalized patients to exclude alternative diagnoses (pneumonia, pneumothorax, pulmonary edema) - chest X-ray changes management in 7-21% of cases 1
• Perform ECG if resting heart rate <60/min or >110/min, or if cardiac symptoms are present 1
• Administer prophylactic subcutaneous heparin for venous thromboembolism prevention in patients with acute-on-chronic respiratory failure 1

What NOT to Do

• Do NOT use chest physiotherapy - no evidence of benefit in acute COPD exacerbations 1
• Do NOT use diuretics unless there is peripheral edema and raised jugular venous pressure 1
• Do NOT initiate pulmonary rehabilitation during hospitalization - this increases mortality 1

Discharge Planning and Post-Exacerbation Management

Timing and Follow-Up

Schedule pulmonary rehabilitation within 3 weeks after discharge - this reduces hospital readmissions and improves quality of life 1. Starting rehabilitation during hospitalization increases mortality, while post-discharge timing reduces admissions 1

Schedule follow-up within 3-7 days to assess response 1. At 8 weeks after an exacerbation, 20% of patients have not recovered to their pre-exacerbation state, highlighting the importance of follow-up care 1

Maintenance Therapy Optimization

Initiate or optimize long-acting bronchodilator therapy before hospital discharge. 1 Maintenance therapy with LAMA, LABA, or LAMA/LABA/ICS combinations should be started as soon as possible 1

Do not step down from triple therapy (LAMA/LABA/ICS) during or immediately after an exacerbation - ICS withdrawal increases recurrent exacerbation risk, particularly in patients with eosinophils ≥300 cells/μL 1

For patients with ≥2 moderate-to-severe exacerbations per year despite optimized triple therapy, consider adding macrolide maintenance therapy (azithromycin 250-500 mg three times weekly), though this requires consideration of potential QT prolongation, hearing loss, and bacterial resistance 1

Prevention Strategies

• Provide intensive smoking cessation counseling with nicotine replacement therapy and behavioral intervention at every visit for current smokers 1
• Review and correct inhaler technique at every visit 1
• Consider roflumilast (PDE-4 inhibitor) for patients with chronic bronchitic phenotype (chronic cough and sputum production) 1

Common Pitfalls to Avoid

1. Excessive oxygen use: Avoid PaO2 above 10.0 kPa due to previous excessive oxygen use, as this increases risk of respiratory acidosis 2
2. Prolonged corticosteroid courses: Never extend beyond 5-7 days for a single exacerbation - longer courses increase pneumonia-associated hospitalization and mortality without additional benefit 3
3. Delaying NIV: Do not delay NIV in patients with acute hypercapnic respiratory failure and acidosis 1
4. Defaulting to IV corticosteroids: Oral administration is equally effective and preferred unless the patient cannot tolerate oral medications 3
5. Using systemic corticosteroids for long-term prevention: No evidence supports use beyond 30 days after the initial exacerbation, and risks (infection, osteoporosis, adrenal suppression) far outweigh any benefits 3