What is the recommended immediate management for an acute chronic obstructive pulmonary disease exacerbation, including bronchodilator therapy, systemic corticosteroids, supplemental oxygen, antibiotics, and criteria for hospital admission?

Management of Acute COPD Exacerbation

For an acute 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; use noninvasive ventilation as first-line for acute hypercapnic respiratory failure. 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. 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. 1

• Power nebulizers with compressed air, not oxygen, when PaCO₂ is elevated or respiratory acidosis is present. 1 Provide supplemental oxygen via low-flow nasal cannula (1–2 L/min) concurrently if needed.

• Avoid intravenous methylxanthines (theophylline/aminophylline) entirely—they increase adverse effects without providing clinical benefit. 2, 1

Systemic Corticosteroid Protocol

• Give oral prednisone 30–40 mg once daily for exactly 5 days, started immediately upon presentation. 2, 1 This short course is as effective as a 14-day regimen 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

• Do not continue systemic corticosteroids beyond 5–7 days after the acute episode unless there is a separate indication. 1 Corticosteroids improve lung function, oxygenation, shorten recovery time and hospital stay, and reduce treatment failure by over 50%. 2, 1

• Corticosteroids prevent hospitalization for subsequent exacerbations within the first 30 days but provide no benefit beyond this window. 1

Oxygen Therapy

• Target oxygen saturation of 88–92% using controlled oxygen delivery (Venturi mask 24–28% FiO₂ or nasal cannula 1–2 L/min). 1 Higher oxygen concentrations can aggravate hypercapnic respiratory failure and increase mortality. 1

• Obtain arterial blood gas within 60 minutes of starting oxygen to identify hypercapnia (PaCO₂ > 45 mmHg) or acidosis (pH < 7.35). 1

• If the initial ABG shows normal pH and PaCO₂, the SpO₂ target may be increased to 94–98% unless the patient has a prior history of hypercapnic failure requiring NIV or their usual stable saturation is < 94%. 1

• Repeat ABG at 30–60 minutes (or sooner if clinical deterioration occurs) to detect rising PaCO₂ or falling pH; a pH < 7.26 with increasing PaCO₂ warrants immediate preparation for NIV. 1

Antibiotic Therapy

• Prescribe antibiotics for 5–7 days when increased sputum purulence is present together with either increased dyspnea OR increased sputum volume (two of three cardinal symptoms). 2, 1 Antibiotics are also indicated when all three cardinal symptoms are present, and in any patient requiring mechanical ventilation. 1

• Antibiotic treatment reduces short-term mortality by approximately 77%, treatment failure by 53%, and sputum purulence by 44%. 1

• First-line agents (selected according to local resistance patterns) include:

  • Amoxicillin-clavulanate 875/125 mg orally twice daily
  • Doxycycline 100 mg orally twice daily
  • Macrolides (azithromycin 500 mg day 1, then 250 mg daily for 4 days) 1, 3

• The most common organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 2, 1

• Alternative treatments include newer cephalosporins or respiratory fluoroquinolones (levofloxacin 750 mg daily or moxifloxacin 400 mg daily) for patients with risk factors for resistant organisms. 1, 3

Noninvasive Ventilation (NIV)

• 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. 2, 1

• NIV improves gas exchange, reduces work of breathing, lowers intubation rates by approximately 50%, shortens hospital stay, and improves survival; success rates in appropriately selected patients are 80–85%. 2, 1

• Contraindications to NIV include: altered mental status with inability to protect the airway, large-volume secretions, hemodynamic instability, or recent facial/upper-airway surgery. 1 If present, prepare for invasive mechanical ventilation.

Criteria for Hospital Admission

Hospitalize or evaluate in the emergency department when any of the following are present: 2, 1

• 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, renal or liver failure)
• Inability to care for oneself at home (lack of support)

Severity Classification

• Mild exacerbations: Treated with short-acting bronchodilators only (outpatient management) 2, 1

• Moderate exacerbations: Require short-acting bronchodilators plus antibiotics and/or oral corticosteroids (typically outpatient) 2, 1

• Severe exacerbations: Require hospitalization or emergency department visit; may be associated with acute respiratory failure 2, 1

Discharge Planning and Follow-Up

• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 2, 1 Do not initiate pulmonary rehabilitation during hospitalization, as this increases mortality. 2, 1

• Initiate or optimize long-acting bronchodilator therapy before hospital discharge (LAMA, LABA, or combinations). 2, 1

• Do not step down from triple therapy (LAMA/LABA/ICS) during or immediately after an exacerbation, as ICS withdrawal increases the risk of recurrent moderate-severe exacerbations. 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 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. 1

• Never power nebulizers with oxygen in patients who develop hypercapnia; instead, use compressed air for nebulization. 1

• Never use methylxanthines (theophylline) in acute exacerbations due to increased side-effect profile without added benefit. 2, 1

• Never delay NIV in patients with acute hypercapnic respiratory failure meeting criteria (pH < 7.35, PaCO₂ > 45 mmHg persisting >30 minutes). 1

• Never extend systemic corticosteroids beyond 5–7 days for a single exacerbation unless there is a separate indication. 1