What are the orders for Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

For a COPD exacerbation, treatment should include short-acting bronchodilators, systemic corticosteroids, and antibiotics when indicated, with the goal of minimizing the negative impact of the current exacerbation and preventing subsequent events. The initial treatment should start with short-acting inhaled β2-agonists, with or without short-acting anticholinergics, as recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1.

Key Treatment Components

• Short-acting bronchodilators: albuterol (2.5 mg via nebulizer or 4-8 puffs via MDI) every 1-4 hours as needed, and ipratropium bromide (0.5 mg via nebulizer or 4-8 puffs via MDI) every 4-6 hours.
• Systemic corticosteroids: prednisone 40 mg orally daily for 5 days, as they improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1.
• Antibiotics: if there are signs of infection (increased sputum purulence, volume, or fever), add an antibiotic such as azithromycin 500 mg on day 1, then 250 mg daily for 4 more days, or doxycycline 100 mg twice daily for 5-7 days, as they shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration 1.

Additional Considerations

• Supplemental oxygen should be provided to maintain oxygen saturation at 88-92% 1.
• For severe exacerbations, consider non-invasive positive pressure ventilation (NIPPV) if the patient has respiratory acidosis (pH < 7.35) with hypercapnia, as recommended by the European Respiratory Society/American Thoracic Society guideline 1. These interventions work by reducing airway inflammation, bronchospasm, and addressing any infectious triggers, which collectively help improve airflow and gas exchange in the compromised lungs. Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge, and appropriate measures for exacerbation prevention should be initiated after an exacerbation 1.

From the FDA Drug Label

Adults

• Acute bacterial exacerbations of chronic obstructive pulmonary disease (mild to moderate) 500 mg QD × 3 days

The orders for COPD exacerbation are 500 mg of azithromycin once daily for 3 days 2.

From the Research

Orders for COPD Exacerbation

The following are the orders for COPD exacerbation:

• Increase the dosage of inhaled short-acting bronchodilators, such as ipratropium and albuterol, to relieve dyspnea 3
• Use oral corticosteroids, especially for patients with purulent sputum 3
• Prescribe antibiotics to reduce the risk of treatment failure and mortality in moderately or severely ill patients, with the choice of antibiotic guided by local resistance patterns and the patient's recent history of antibiotic use 3
• Provide regular doses of short-acting bronchodilators, continuous supplemental oxygen, antibiotics, and systemic corticosteroids for hospitalized patients 3
• Use noninvasive positive pressure ventilation or invasive mechanical ventilation in patients with worsening acidosis or hypoxemia 3
• Titrate targeted O2 therapy to an SpO2 of 88-92% to improve outcomes 4
• Use inhaled short-acting bronchodilators via nebulizer, pressurized metered-dose inhaler, or dry powder inhaler 4
• Consider noninvasive ventilation (NIV) as standard therapy for patients with COPD exacerbation 4
• Manage auto-PEEP and address trigger asynchrony and cycle asynchrony to improve patient-ventilator interaction in mechanically ventilated patients 4
• Extubate patients to NIV and consider care coordination to improve the effectiveness of care 4

Pharmacologic Management

The following pharmacologic management options are available:

• Dual bronchodilators to maximize bronchodilation and reduce exacerbations 5
• Triple therapy, including inhaled corticosteroids, for patients with continuing exacerbations, especially if blood eosinophils are elevated 6
• Phosphodiesterase inhibitors and macrolide antibiotics as alternative options 6
• Corticosteroids or antibiotics to attenuate the length and severity of an established exacerbation 6

Prevention and Disease Impact

The following strategies can help prevent COPD exacerbations and reduce their impact:

• Multidisciplinary disease-management programs, including pulmonary rehabilitation, follow-up appointments, aftercare, inhaler training, and patient education 5
• Timely and appropriate maintenance pharmacotherapy to reduce exacerbations 5
• Preventative measures, such as dual bronchodilators and triple therapy, to reduce the risk of future events 6
• Targeted therapies directed towards specific pathways of inflammation to prevent exacerbations 6