What is the recommended treatment for an acute COPD exacerbation, including oxygen therapy, short‑acting bronchodilators, systemic corticosteroids, antibiotics if infection is suspected, and indications for non‑invasive or invasive ventilation?

Treatment of Acute COPD Exacerbation

For acute COPD exacerbations, immediately initiate short-acting bronchodilators (SABA with or without SAMA), systemic corticosteroids (prednisone 30-40 mg daily for exactly 5 days), controlled oxygen targeting SpO2 88-92%, and antibiotics (5-7 days) when increased sputum purulence is present with either increased dyspnea or sputum volume; use noninvasive ventilation as first-line for acute hypercapnic respiratory failure. 1, 2

Oxygen Therapy

• Target oxygen saturation of 88-92% using controlled delivery devices (Venturi mask or nasal cannula) to prevent CO2 retention and worsening respiratory acidosis 1, 2
• Obtain arterial blood gas within 60 minutes of initiating oxygen to assess for hypercapnia and acidosis 1, 2
• Titrated oxygen reduces mortality by 78% compared to high-flow oxygen in the out-of-hospital setting 1
• If initial blood gas shows normal pH and PaCO2, target may be increased to 94-98% unless the patient has prior history of hypercapnic failure requiring NIV 2
• Avoid excessive oxygenation—keep PaO2 ≤10.0 kPa (75 mmHg) to reduce respiratory acidosis risk 2

Bronchodilator Therapy

• Combine short-acting β2-agonists (salbutamol 2.5-5 mg) with short-acting anticholinergics (ipratropium 0.25-0.5 mg) via nebulizer or MDI with spacer every 4-6 hours during the acute phase 1, 2
• This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 2
• Nebulizers are preferred over MDI in sicker hospitalized patients because they are easier to use and don't require coordination of 20+ inhalations 2
• Verify and correct inhaler technique at every visit—improper technique is a common cause of treatment failure 2
• Do NOT use intravenous methylxanthines (theophylline/aminophylline)—they increase side effects without added benefit 1, 2, 3

Systemic Corticosteroids

• Administer prednisone 30-40 mg orally once daily for exactly 5 days starting immediately 1, 2
• This 5-day course is equally effective as 14-day courses but reduces cumulative steroid exposure by >50% 2
• Corticosteroids improve lung function (FEV1), oxygenation, shorten recovery time and hospitalization duration, and reduce treatment failure by >50% 1, 2, 4
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 2
• Do NOT continue corticosteroids beyond 5-7 days after the acute episode unless there is a separate indication 1, 2
• Corticosteroids may be less efficacious in patients with lower blood eosinophil levels 2

Antibiotic Therapy

Indications for Antibiotics

• Prescribe antibiotics when the patient has increased sputum purulence PLUS either increased dyspnea OR increased sputum volume (two of three cardinal symptoms with purulence being one) 1, 2, 5
• Also give antibiotics if all three cardinal symptoms are present (increased dyspnea, sputum volume, and purulence) 1, 5
• Always give antibiotics to patients requiring mechanical ventilation (invasive or noninvasive) 1, 5
• Antibiotics reduce short-term mortality by 77%, treatment failure by 53%, and sputum purulence by 44% 1, 2

Antibiotic Selection and Duration

• First-line choices (based on local resistance patterns): amoxicillin/clavulanate, amoxicillin, doxycycline, or macrolides (azithromycin, clarithromycin) 1, 2, 5
• Recommended duration is 5-7 days 1, 2, 5
• For patients with frequent exacerbations, severe airflow limitation, or requiring mechanical ventilation, obtain sputum cultures to identify resistant pathogens 1, 5
• Consider respiratory fluoroquinolones (levofloxacin, moxifloxacin) for patients who have failed prior antibiotic therapy 1, 2
• Most common organisms: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses 2, 5

Ventilatory Support

Noninvasive Ventilation (NIV)

• Initiate NIV immediately as first-line therapy for patients with acute hypercapnic respiratory failure (PaCO2 >6 kPa/45 mmHg) and acidosis (pH <7.35) persisting >30 minutes after standard medical management 1, 2, 4
• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospitalization duration, and improves survival 1, 2, 4
• Success rate of NIV is 80-85% in appropriate patients 1
• Contraindications include inability to protect airway, hemodynamic instability, severe confusion, and large volumes of secretions 2

Invasive Mechanical Ventilation

• Indications include failure of initial NIV trial, inability to protect airway, severe hemodynamic instability, or respiratory arrest 1, 4
• Patients who fail NIV and receive invasive ventilation as rescue therapy have greater morbidity, longer hospital stays, and higher mortality 1
• Do NOT delay intubation if NIV fails—early intubation is preferable to emergent intubation in extremis 4

Indications for Hospitalization

• Marked increase in dyspnea intensity that does not respond to initial outpatient management 1, 2
• Severe underlying COPD with new physical signs (e.g., cyanosis, peripheral edema) 1, 2
• Inability to eat or sleep due to respiratory symptoms 1, 2
• New or worsening hypoxemia or hypercapnia 2
• Altered mental status or loss of alertness 1, 2
• Significant comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/liver failure) 1, 2
• Frequent exacerbations or diagnostic uncertainty 2
• Older age or inability to care for self at home 2

Indications for ICU Admission

• Respiratory rate >30 breaths/min 2, 4
• Impending or actual respiratory failure 1
• Severe acidosis (pH <7.30) or PaO2/FiO2 <250 mmHg 4
• Hemodynamic instability (systolic BP <90 mmHg) 4
• Presence of other end-organ dysfunction (shock, renal, liver, or neurological disturbance) 1, 4

Discharge Planning and Follow-Up

• Schedule pulmonary rehabilitation within 3 weeks after discharge—this reduces hospital readmissions and improves quality of life 2
• Do NOT initiate pulmonary rehabilitation during hospitalization—this increases mortality 2
• Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) before hospital discharge 2, 4
• Do NOT step down from triple therapy (LAMA/LABA/ICS) during or immediately after an exacerbation—ICS withdrawal increases recurrent exacerbation risk 2
• Provide intensive smoking cessation counseling at every visit 2
• Review and correct inhaler technique 2
• Assess and optimize management of comorbidities 1
• Lack of spirometric assessment and arterial blood gas analysis has been associated with rehospitalization and mortality 1

Common Pitfalls to Avoid

• Avoid high-flow oxygen (>28% FiO2 or >4 L/min) without blood gas monitoring—this can worsen hypercapnic respiratory failure and increase mortality 1, 2
• Do NOT use chest physiotherapy—no evidence of benefit in acute COPD exacerbations 2
• Do NOT prescribe antibiotics for viral bronchitis without bacterial infection criteria 5
• Do NOT continue empiric therapy when cultures identify resistant organisms 4, 5
• Do NOT use diuretics unless peripheral edema and elevated jugular venous pressure are present 2
• Avoid delaying NIV in patients with acute hypercapnic respiratory failure 2

Additional Supportive Measures

• Administer prophylactic subcutaneous heparin for venous thromboembolism prevention in patients with acute-on-chronic respiratory failure 2
• Monitor fluid balance and nutrition status 2
• Obtain chest radiograph on all hospitalized patients to exclude alternative diagnoses (pneumonia, pneumothorax, pulmonary edema) 2
• Perform ECG if resting heart rate <60/min or >110/min, or if cardiac symptoms are present 2