How should an adult patient with an acute COPD exacerbation be treated?

Treatment for COPD Exacerbation

For an adult with 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 30–40 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 increased sputum volume. 1

Immediate Assessment and Oxygen Management

Upon presentation, obtain arterial blood gas within 60 minutes, chest radiograph, complete blood count, electrolytes, and ECG to identify life-threatening features (altered mental status, severe hypoxemia with PaO₂ <50 mmHg, respiratory acidosis with pH <7.35, or hemodynamic instability). 2

Target oxygen saturation of 88–92% using controlled-delivery devices (Venturi mask at 24–28% FiO₂ or nasal cannula at 1–2 L/min). 1 Higher oxygen concentrations can worsen hypercapnic respiratory failure and increase mortality by approximately 78%. 1 Repeat arterial blood gas at 30–60 minutes after initiating oxygen to detect rising PaCO₂ or falling pH. 1 If initial pH and PaCO₂ are normal and the patient has no prior hypercapnic failure requiring NIV, you may increase the target to 94–98%. 1

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 every 4–6 hours during the acute phase. 1 This combination provides superior bronchodilation lasting 4–6 hours compared with either agent alone. 1 For patients able to coordinate inhalation, metered-dose inhalers with a spacer are equally effective. 1

Never use intravenous methylxanthines (theophylline or aminophylline) because they increase adverse effects without clinical benefit. 1, 2

When nebulizing in hypercapnic patients, power nebulizers with compressed air (not oxygen) and provide supplemental oxygen via a separate nasal cannula. 1

Systemic Corticosteroid Protocol

Give oral prednisone 30–40 mg once daily for exactly 5 days starting immediately. 1, 2 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

The 5-day regimen improves lung function and oxygenation, shortens recovery time and hospital stay, reduces treatment failure by over 50%, and lowers the risk of rehospitalization within the first 30 days. 1 Do not extend systemic corticosteroids beyond 5–7 days unless another indication exists. 1, 2

Antibiotic Therapy

Prescribe antibiotics for 5–7 days when sputum purulence is present together with either increased dyspnea or increased sputum volume (two of three cardinal symptoms, with purulence required). 1, 2 This approach 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 1, 2
• Doxycycline 100 mg orally twice daily 1, 2
• Macrolides (azithromycin or clarithromycin) as alternatives 1, 2

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

Non-Invasive 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 treatment. 1, 2 Additional indications include persistent hypoxemia despite supplemental oxygen or severe dyspnea with respiratory muscle fatigue. 1, 2

NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospital stay, and improves survival; success rates in appropriately selected patients are 80–85%. 1, 2 If pH remains <7.26 despite NIV, transfer to ICU for consideration of invasive mechanical ventilation. 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

Hospitalization Criteria

Admit or evaluate in the emergency department if any of the following are present:

• Marked increase in dyspnea unresponsive to outpatient therapy 1, 2
• Respiratory rate >30 breaths/min 1
• Inability to eat or sleep because of respiratory symptoms 1, 2
• New or worsening hypoxemia (SpO₂ <90% on room air) 1, 2
• New or worsening hypercapnia (PaCO₂ >45 mmHg) 1, 2
• Altered mental status or loss of alertness 1, 2
• High-risk comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes, renal or liver failure) 1, 2
• Inability to care for self at home 1, 2
• Persistent rhonchi after initial treatment requiring continued nebulization 1

Discharge Planning and Follow-Up

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

Optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) before discharge. 1, 2 Do not step down from triple therapy (LAMA + LABA + ICS) during or immediately after an exacerbation, as inhaled corticosteroid withdrawal raises the risk of recurrent exacerbations. 1

Verify proper inhaler technique with the patient at discharge. 1 Provide smoking cessation counseling with nicotine replacement therapy and behavioral support for current smokers. 1

Arrange follow-up within 30 days after discharge to review therapy and make necessary adjustments, with additional follow-up at 3 months to ensure return to stable state. 2

Common Pitfalls to Avoid

• Never power nebulizers with oxygen in hypercapnic patients; use compressed air and provide supplemental oxygen via a separate nasal cannula 1
• Never delay NIV when criteria for acute hypercapnic respiratory failure are met (pH <7.35, PaCO₂ >45 mmHg persisting >30 minutes) 1
• Never use methylxanthines (theophylline/aminophylline) in acute exacerbations—they add toxicity without benefit 1, 2
• Never continue systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists 1, 2
• Never administer high-flow oxygen without arterial blood-gas monitoring, as this can worsen hypercapnic respiratory failure and increase mortality 1