What is the recommended acute management for an adult patient experiencing a COPD exacerbation?

COPD Exacerbation Treatment

For adults experiencing a COPD exacerbation, immediately initiate short-acting bronchodilators, systemic corticosteroids (prednisolone 30-40 mg daily for 5-7 days), and antibiotics if at least two cardinal symptoms are present (increased dyspnea, increased sputum volume, or purulent sputum), while providing controlled oxygen therapy targeting 88-92% saturation. 1, 2

Immediate Assessment and Stabilization

Initial Evaluation

• Obtain arterial blood gas analysis, chest radiograph, complete blood count, electrolytes, and ECG immediately upon presentation 2
• Record baseline FEV1 and/or peak flow when feasible 2
• Assess for life-threatening features requiring ICU admission: altered mental status, severe hypoxemia (PaO2 <50 mmHg), respiratory acidosis (pH <7.35), or hemodynamic instability 2
• Send sputum for culture if purulent; consider blood cultures if pneumonia is suspected 2

Oxygen Therapy

• Target oxygen saturation of 88-92% to correct hypoxemia while avoiding CO2 retention 2
• Use controlled oxygen delivery via Venturi mask (FiO2 ≤28%) or nasal cannula (≤2 L/min) until arterial blood gases are known 2
• Critical pitfall: High-flow oxygen can worsen hypercapnia and precipitate respiratory failure in COPD patients 2
• Recheck arterial blood gases within 60 minutes of starting oxygen and after any change in inspired oxygen concentration 2

Pharmacologic Management

Bronchodilator Therapy

• Administer nebulized short-acting bronchodilators immediately upon arrival and continue at 4-6 hour intervals 1, 2
• For moderate exacerbations, use either a beta-agonist or anticholinergic 2
• For severe exacerbations, use both beta-agonist and anticholinergic combination therapy 2
• Important caveat: While ipratropium is commonly used, the FDA notes it has not been adequately studied as a single agent for acute COPD exacerbations, and combination with beta-agonists has not been shown more effective than either drug alone 3

Systemic Corticosteroid Therapy

• Prescribe oral prednisolone 30-40 mg daily for exactly 5-7 days for all COPD exacerbations requiring medical attention 1, 2, 4
• Oral and intravenous routes are equally effective; use oral unless patient cannot tolerate oral intake 2
• Systemic corticosteroids improve lung function, oxygenation, shorten recovery time, and reduce hospitalization duration 2
• Discontinue after 5-7 days unless specifically indicated for long-term treatment 2
• Critical pitfall: Avoid prolonged courses beyond 7-14 days due to increased adverse effects without additional benefit 2

Antibiotic Therapy

• Prescribe antibiotics when patients present with at least two of three cardinal symptoms: increased dyspnea, increased sputum volume, and purulent sputum 1, 2
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 2
• First-line options: amoxicillin or tetracycline 2
• Second-line options: broad-spectrum cephalosporins or newer macrolides (azithromycin is FDA-approved for acute bacterial exacerbations of COPD due to H. influenzae, M. catarrhalis, or S. pneumoniae) 2, 5
• Tailor antibiotic selection based on local resistance patterns, affordability, and patient history 1

Ventilatory Support

Noninvasive Ventilation (NIV)

• Initiate NIV as first-line ventilatory support for patients with acute or acute-on-chronic respiratory failure 2
• Specific indications: persistent hypoxemia despite supplemental oxygen, respiratory acidosis (pH <7.35), or severe dyspnea with signs of respiratory muscle fatigue 2
• NIV reduces mortality and intubation rates by 80-85% in appropriate patients 2
• Critical caveat: NIV should never delay intubation if indicated 6

Invasive Mechanical Ventilation

• Consider invasive mechanical ventilation if NIV fails 2
• Focus on avoiding ventilator-induced lung injury and minimizing intrinsic positive end-expiratory pressure 6, 7
• May require limiting ventilation and "permissive hypercapnia" 7

Post-Exacerbation Management

Follow-up and Monitoring

• Arrange follow-up within 30 days after discharge to review discharge therapy and make necessary adjustments 2
• Schedule additional follow-up at 3 months to ensure return to stable state 2
• Important: 20% of patients have not recovered to pre-exacerbation baseline at 8 weeks post-exacerbation 4

Pulmonary Rehabilitation

• Initiate early pulmonary rehabilitation within 3 weeks after hospital discharge to improve exercise capacity, reduce healthcare costs, and decrease future exacerbation rates 2, 4

Preventive Measures

• Provide intensive smoking cessation counseling with nicotine replacement therapy at every visit for current smokers 4
• Ensure influenza and pneumococcal vaccination 8