What is the recommended acute management for an adult with chronic obstructive pulmonary disease presenting with an exacerbation characterized by increased dyspnea, cough, and sputum volume or purulence?

Acute Management of COPD Exacerbation

Immediately initiate combined short-acting bronchodilators (salbutamol 2.5–5 mg plus ipratropium 0.25–0.5 mg via nebulizer every 4–6 hours), oral prednisone 40 mg daily for exactly 5 days, controlled oxygen targeting SpO₂ 88–92%, and antibiotics for 5–7 days when sputum purulence is present with either increased dyspnea or sputum volume. 1

Immediate Bronchodilator Therapy

• Administer combined short-acting β₂-agonist (salbutamol 2.5–5 mg) with 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
• This combination provides superior bronchodilation lasting 4–6 hours compared to either agent alone. 1
• For sicker hospitalized patients, nebulizers are preferred because they are easier to use and don't require coordination of 20+ inhalations needed to match nebulizer efficacy. 1
• Power nebulizers with compressed air, not oxygen, when hypercapnia is suspected, while delivering supplemental oxygen via low-flow nasal cannula (1–2 L/min) concurrently. 1
• Continue repeat dosing every 4–6 hours for 24–48 hours until clinical improvement occurs. 1

Systemic Corticosteroid Protocol

• Give oral prednisone 30–40 mg once daily for exactly 5 days starting immediately—this short course is as effective as 14-day regimens while reducing cumulative steroid exposure by more than 50%. 1
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake. 1
• Systemic corticosteroids improve lung function, oxygenation, shorten recovery time and hospitalization duration, and reduce treatment failure by over 50%. 1
• Do not continue corticosteroids beyond 5–7 days after the acute episode unless there is a separate indication for long-term treatment. 1
• Corticosteroids prevent hospitalization for subsequent exacerbations within the first 30 days but provide no benefit beyond this window. 1

Antibiotic Therapy Criteria and Selection

• 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 with purulence being one). 1
• Antibiotic therapy reduces short-term mortality by approximately 77%, treatment failure by 53%, and sputum purulence by 44%. 1
• First-line antibiotic choices (based on local resistance patterns): 1
  • Amoxicillin-clavulanate 875/125 mg orally twice daily
  • Doxycycline 100 mg orally twice daily
  • Azithromycin 500 mg day 1, then 250 mg daily for 4 days
• The most common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 1
• For the FDA-approved azithromycin regimen in COPD exacerbations, clinical cure rates at Day 21–24 were 85% with 3 days of azithromycin (500 mg once daily). 2

Controlled Oxygen Therapy

• Target oxygen saturation of 88–92% using controlled oxygen delivery (24–28% Venturi mask or 1–2 L/min nasal cannula) to correct life-threatening hypoxemia while minimizing CO₂ retention. 1
• Higher oxygen concentrations can aggravate hypercapnic respiratory failure and increase mortality in COPD patients. 1
• Obtain arterial blood gas within 60 minutes of initiating oxygen to assess for worsening hypercapnia (PaCO₂ > 45 mmHg) or acidosis (pH < 7.35). 1
• If initial ABG shows normal pH and PaCO₂, the SpO₂ target may be increased to 94–98% unless the patient has prior history of hypercapnic failure requiring NIV or usual stable saturation is < 94%. 1
• Repeat ABG at 30–60 minutes (or sooner if clinical deterioration) to detect rising PaCO₂ or falling pH. 1

Non-Invasive Ventilation for Respiratory Failure

• Initiate NIV immediately as first-line therapy when acute hypercapnic respiratory failure (PaCO₂ > 45 mmHg) with acidosis (pH < 7.35) persists for more than 30 minutes after standard medical management. 1
• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospitalization duration, and improves survival. 1
• Success rates in appropriately selected patients are 80–85%. 1
• If pH falls below 7.26 with rising PaCO₂, prepare for immediate NIV. 1

Hospitalization Criteria

Admit to hospital or evaluate in emergency department for any of the following: 1

• Marked increase in dyspnea unresponsive to initial 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 oneself at home

Medications to Avoid

• Do not use intravenous methylxanthines (theophylline or aminophylline)—they increase side effects without added clinical benefit. 1
• Avoid cough suppressants during acute exacerbations, as productive cough is a necessary clearance mechanism. 3
• Do not use chest physiotherapy in acute COPD exacerbations—there is no evidence of benefit. 1

Discharge Planning and Follow-Up

• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 1
• Do not initiate pulmonary rehabilitation during hospitalization, as this increases mortality; wait until post-discharge. 1
• Continue or optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) before hospital discharge. 1
• Do not step down from triple therapy (LAMA/LABA/ICS) during or immediately after an exacerbation, as ICS withdrawal increases recurrent exacerbation risk. 1
• Verify proper inhaler technique at every visit, as improper use is a common cause of treatment failure. 1
• Provide intensive smoking cessation counseling with nicotine replacement therapy and behavioral intervention at every visit for current smokers. 1

Common Pitfalls to Avoid

• Never power nebulizers with oxygen in hypercapnic patients—use compressed air and provide supplemental oxygen separately via nasal cannula. 1
• Do not administer high-flow oxygen (> 28% FiO₂ or > 4 L/min) without arterial blood gas monitoring, as this can worsen hypercapnic respiratory failure and increase mortality. 1
• Do not delay NIV in patients with acute hypercapnic respiratory failure—immediate initiation is critical. 1
• Do not extend systemic corticosteroids beyond 5–7 days without a separate indication to avoid unnecessary steroid-related adverse effects. 1
• Do not reflexively prescribe antibiotics without assessing for the presence of at least two cardinal symptoms with purulence being one. 1