What is the appropriate outpatient management for an acute COPD exacerbation in an adult with known COPD who is not hypoxic enough to require hospital admission?

Outpatient Management of COPD Exacerbation

For an adult with acute COPD exacerbation managed in the outpatient setting, immediately initiate short-acting bronchodilators (salbutamol with or without ipratropium), prednisone 30-40 mg orally 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

Short-acting bronchodilators are the cornerstone of acute treatment:

• Administer salbutamol (albuterol) 2.5-5 mg via metered-dose inhaler with spacer or nebulizer, with or without ipratropium bromide 0.25-0.5 mg, every 4-6 hours as needed 2, 1
• The combination of beta-agonist plus anticholinergic provides superior bronchodilation lasting 4-6 hours compared to either agent alone 1
• Metered-dose inhalers with spacer devices are equally effective as nebulizers for most outpatients and should be the preferred delivery method 2, 1
• Verify and correct inhaler technique at every visit—this is a critical step often overlooked 2, 1
• Consider adding a long-acting bronchodilator if the patient is not already using one 2

Avoid methylxanthines (theophylline) entirely—they increase side effects without added benefit 1, 3

Systemic Corticosteroid Protocol

Prednisone 30-40 mg orally once daily for exactly 5 days is the evidence-based standard 2, 1, 3:

• This 5-day regimen is equally effective as 14-day courses but reduces cumulative steroid exposure by over 50% 1
• Systemic corticosteroids improve lung function, oxygenation, shorten recovery time, and reduce treatment failure by over 50% 1
• Do not extend beyond 5-7 days unless there is a separate indication—longer courses provide no additional benefit and increase adverse effects 1
• Corticosteroids prevent hospitalization for subsequent exacerbations within the first 30 days 1

Antibiotic Therapy

Prescribe antibiotics for 5-7 days when the patient has increased sputum purulence PLUS either increased dyspnea OR increased sputum volume 1, 3:

First-line antibiotic choices (based on local resistance patterns) 2, 1:

• Amoxicillin/clavulanate (preferred for broader coverage)
• Amoxicillin or ampicillin
• Doxycycline
• Macrolides (azithromycin, clarithromycin)

For patients who have failed prior antibiotic therapy 2:

• Amoxicillin/clavulanate
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin)

The most common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 3

Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% when appropriately indicated 1

Indications for Hospitalization

Recognize when outpatient management is inadequate and hospital admission is required 2, 1:

• Marked increase in dyspnea that does not respond to initial outpatient treatment
• Inability to eat or sleep due to symptoms
• Worsening hypoxemia or new hypoxemia
• Worsening or new hypercapnia
• Changes in mental status or loss of alertness
• High-risk comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes, renal or liver failure)
• Inability of the patient to care for themselves (lack of home support)
• Uncertain diagnosis
• Severe underlying COPD

Follow-Up and Prevention

Schedule follow-up within 3-7 days to assess response to treatment 1:

• Review inhaler technique again—this cannot be overemphasized 1
• Provide intensive smoking cessation counseling with nicotine replacement therapy and behavioral intervention for current smokers 1
• Optimize maintenance therapy with long-acting bronchodilators (LAMA, LABA, or LAMA/LABA/ICS combinations) before the patient leaves your office 1
• Do not step down from triple therapy during or immediately after an exacerbation—ICS withdrawal increases recurrent exacerbation risk 1
• Consider pulmonary rehabilitation referral, though this should be scheduled at least 3 weeks after the acute episode (not during) 1

Common Pitfalls to Avoid

• Never use corticosteroids beyond 5-7 days for a single exacerbation—there is no benefit and significant harm 1
• Never prescribe antibiotics without clear indication (purulent sputum plus increased dyspnea or volume)—inappropriate use drives resistance 1, 3
• Never use theophylline in acute exacerbations—the side effect profile outweighs any marginal benefit 1, 3
• Never assume the patient is using their inhaler correctly—directly observe technique at every visit 2, 1
• Never delay hospital referral when warning signs are present—early recognition of severe exacerbations reduces mortality 2, 1