What is the appropriate initial management for an adult with chronic obstructive pulmonary disease exacerbation?

COPD Exacerbation Treatment

Immediately initiate short-acting bronchodilators (SABA plus SAMA), oral prednisone 40 mg daily for exactly 5 days, and antibiotics when sputum purulence is present with either increased dyspnea or sputum volume; use noninvasive ventilation as first-line for acute hypercapnic respiratory failure. 1, 2

Immediate Bronchodilator Therapy

Administer combined short-acting β2-agonist (salbutamol 2.5-5 mg) plus short-acting anticholinergic (ipratropium 0.25-0.5 mg) via nebulizer or metered-dose inhaler 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 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. 2
• Metered-dose inhalers with spacer are equally effective for most outpatients and should be the preferred delivery device. 2
• Avoid intravenous methylxanthines (theophylline/aminophylline)—they increase side effects without added benefit. 1, 2

Systemic Corticosteroid Protocol

Give oral prednisone 30-40 mg once daily for exactly 5 days starting immediately. 1, 2 This regimen is as effective as 14-day courses but reduces cumulative steroid exposure by over 50%. 2

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake. 2
• Corticosteroids improve lung function, oxygenation, shorten recovery time, reduce treatment failure by over 50%, and prevent hospitalization for subsequent exacerbations within the first 30 days. 2, 3
• Do not continue systemic corticosteroids beyond 5-7 days after the acute episode unless there is a separate indication. 2

Antibiotic Therapy Criteria

Prescribe antibiotics for 5-7 days when the patient has increased sputum purulence PLUS either increased dyspnea OR increased sputum volume (two of three cardinal symptoms). 1, 2, 3

• Antibiotics reduce short-term mortality by approximately 77%, treatment failure by 53%, and sputum purulence by 44%. 2
• First-line agents (based on local resistance patterns) include:
  • Amoxicillin-clavulanate 875/125 mg orally twice daily 2, 4
  • Doxycycline 100 mg orally twice daily 2
  • Macrolides (azithromycin, clarithromycin) as alternatives 2
• The most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 2

Oxygen Management for Severe Exacerbations

Target oxygen saturation of 88-92% using controlled oxygen delivery (Venturi mask 24-28% or nasal cannula 1-2 L/min) to avoid CO2 retention. 2, 3

• Obtain arterial blood gas within 60 minutes of initiating oxygen to assess for worsening hypercapnia or acidosis. 2
• Higher oxygen concentrations can worsen hypercapnic respiratory failure and increase mortality in COPD patients. 2
• If pH < 7.26 with rising PaCO2, prepare for immediate noninvasive ventilation. 2

Noninvasive Ventilation (NIV) for Respiratory Failure

Initiate NIV immediately as first-line therapy for patients with acute hypercapnic respiratory failure (PaCO2 > 45 mmHg) and acidosis (pH < 7.35) persisting > 30 minutes after standard medical management. 1, 2, 3

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospitalization duration, and improves survival. 1, 2
• Success rates in appropriately selected patients are 80-85%. 2
• Contraindications to NIV include: altered mental status with inability to protect airway, large volume of secretions, hemodynamic instability, or recent facial surgery. 2

Hospitalization Criteria

Admit to hospital or evaluate in emergency department for any of the following: 2

• Marked increase in dyspnea unresponsive to outpatient therapy
• Respiratory rate > 30 breaths/min
• Inability to eat or sleep because of respiratory symptoms
• New or worsening hypoxemia (SpO2 < 90% on room air)
• New or worsening hypercapnia (PaCO2 > 45 mmHg)
• Altered mental status or loss of alertness
• Persistent rhonchi after initial treatment requiring continued nebulization
• High-risk comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes)
• Inability to care for self at home

Discharge Planning and Follow-Up

Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 1, 2 Starting rehabilitation during hospitalization increases mortality, while post-discharge timing reduces admissions. 2

• Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) before hospital discharge. 2
• 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. 2
• Provide intensive smoking cessation counseling at every visit for current smokers. 2
• Verify and correct inhaler technique at every visit—improper use is a common cause of treatment failure. 2

Common Pitfalls to Avoid

• Never power nebulizers with oxygen in patients with hypercapnia—use compressed air for nebulization and provide supplemental oxygen via low-flow nasal cannula (1-2 L/min) concurrently. 2
• Do not administer high-flow oxygen (>28% FiO2 or >4 L/min) without arterial blood-gas monitoring, as this can exacerbate hypercapnic respiratory failure and increase mortality. 2
• Avoid delaying NIV in patients with acute hypercapnic respiratory failure—immediate initiation is critical. 2
• Do not use systemic corticosteroids beyond 5-7 days for a single exacerbation unless there is a separate indication. 2