How should an acute COPD exacerbation be assessed and managed?

Assessment and Management of Acute COPD Exacerbation

Immediately initiate 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, 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 sputum volume; use non-invasive ventilation as first-line for acute hypercapnic respiratory failure. 1

Immediate Severity Assessment

Determine disposition within the first 15 minutes by assessing for any of the following severe features that mandate hospital admission or emergency department evaluation: 1, 2

• Loss of alertness or altered mental status – indicates severe exacerbation requiring immediate hospitalization 1, 2
• Respiratory rate > 30 breaths/min – signals impending respiratory failure 1
• Inability to eat or sleep due to respiratory symptoms – reflects severe functional impairment 1
• Marked increase in dyspnea unresponsive to outpatient therapy – suggests need for escalated care 1
• SpO₂ < 90% on room air – indicates significant hypoxemia 1
• Persistent rhonchi after initial bronchodilator treatment – suggests ongoing airway obstruction requiring continued nebulization 1

If any of these features are present, proceed with hospital-based management. If severity is uncertain, default to hospital evaluation rather than outpatient management. 3, 2

Oxygen Therapy Protocol

Target SpO₂ 88–92% using controlled-delivery devices (Venturi mask 24–28% or nasal cannula 1–2 L/min) to correct hypoxemia while preventing CO₂ retention. 1 High-flow oxygen (>28% FiO₂ or >4 L/min) without blood gas monitoring worsens hypercapnic respiratory failure and increases mortality by approximately 78%. 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 patient deteriorates or initial pH is < 7.35, repeat ABG at 30–60 minutes. 1 When initial ABG shows normal pH and PaCO₂, you may increase the target to 94–98% only if the patient has no prior hypercapnic failure requiring NIV and their usual stable saturation is ≥ 94%. 1

Bronchodilator Therapy

Administer combined salbutamol 2.5–5 mg plus ipratropium 0.25–0.5 mg via nebulizer every 4–6 hours during the acute phase (typically 24–48 hours until clinical improvement). 1 This combination provides superior bronchodilation lasting 4–6 hours compared with either agent alone. 1

Power nebulizers with compressed air, not oxygen, when PaCO₂ is elevated or respiratory acidosis is present; provide supplemental oxygen via separate nasal cannula (1–2 L/min) concurrently. 1 For patients able to coordinate inhalation, metered-dose inhalers with spacer are equally effective. 1

Never use intravenous methylxanthines (theophylline/aminophylline) – they increase adverse effects without clinical benefit. 1

Systemic Corticosteroid Protocol

Give oral prednisone 30–40 mg once daily for exactly 5 days starting immediately. 1 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 oral intake is impossible. 1

This regimen improves lung function and oxygenation, shortens recovery time and hospital stay, reduces treatment failure by over 50%, and lowers 30-day rehospitalization risk. 1 Do not extend systemic corticosteroids beyond 5–7 days unless another indication exists, as longer courses increase adverse effects without added benefit. 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, with purulence required). 1 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): 1

• Amoxicillin-clavulanate 875/125 mg orally twice daily – preferred for broader coverage
• Doxycycline 100 mg orally twice daily – acceptable alternative
• Macrolides (azithromycin or clarithromycin) – alternative option

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 Additional indications include persistent hypoxemia despite oxygen or severe dyspnea with respiratory muscle fatigue. 1

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 If pH remains < 7.26 despite NIV, transfer to ICU. 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; these patients require invasive mechanical ventilation. 1

Diagnostic Testing for Hospitalized Patients

Obtain chest radiograph on all hospitalized patients to exclude alternative diagnoses (pneumonia, pneumothorax, pulmonary edema), as imaging changes management in 7–21% of cases. 1, 3

Perform ECG if resting heart rate < 60/min or > 110/min, or if cardiac symptoms are present to identify arrhythmias or cardiac ischemia. 1

Obtain comprehensive metabolic panel and complete blood count to detect electrolyte disturbances, acute kidney injury, hyperglycemia, and infection. 1

Discharge Planning and Follow-Up

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

Optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) before discharge. 1 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 and provide smoking cessation counseling with nicotine replacement therapy and behavioral support for current smokers. 1

Common Pitfalls to Avoid

• Never power nebulizers with oxygen in hypercapnic patients – use compressed air and provide supplemental oxygen via separate nasal cannula 1
• Never delay NIV when criteria are met (pH < 7.35, PaCO₂ > 45 mmHg persisting >30 minutes) 1
• Never use methylxanthines in acute exacerbations – they add toxicity without benefit 1
• Never continue systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists 1
• Never administer high-flow oxygen without arterial blood-gas monitoring – this can worsen hypercapnic respiratory failure and increase mortality 1
• Never delay hospital evaluation if severity is uncertain – default to hospital assessment 3, 2