How should an acute COPD exacerbation be managed?

Management of 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 only when sputum purulence is present with either increased dyspnea or increased sputum volume. 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 immediately upon arrival. 1, 2 This combination provides superior bronchodilation lasting 4–6 hours compared to either agent alone. 1

• Repeat dosing every 4–6 hours during the acute phase (typically 24–48 hours) until clinical improvement occurs. 3, 1

• Power nebulizers with compressed air, not oxygen, when PaCO₂ is elevated or respiratory acidosis is present; provide supplemental oxygen via separate nasal cannula at 1–2 L/min during nebulization. 3, 1

• For patients able to coordinate inhalation, metered-dose inhalers with spacer are equally effective as nebulizers. 1

• Never use intravenous methylxanthines (theophylline/aminophylline)—they increase adverse effects without clinical benefit. 3, 1, 2

Systemic Corticosteroid Protocol

• Prescribe oral prednisone 40 mg once daily for exactly 5 days starting immediately. 1, 2 This short course is as effective as 14-day regimens while reducing cumulative steroid exposure by >50%. 1

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake. 1

• This regimen improves lung function, oxygenation, shortens recovery time and hospital stay, and reduces treatment failure by >50%. 1

• Do not extend systemic corticosteroids beyond 5–7 days unless there is a separate indication for long-term treatment. 3, 1, 2

Antibiotic Therapy Decision Algorithm

• Prescribe antibiotics for 5–7 days only when increased sputum purulence is present AND at least one of the following: increased dyspnea OR increased sputum volume (two of three cardinal symptoms, with purulence required). 1, 2

• This approach reduces short-term mortality by ~77%, treatment failure by ~53%, and sputum purulence by ~44%. 1

• First-line agents (selected according to local resistance patterns): 1, 2, 4

  • Amoxicillin-clavulanate 875/125 mg orally twice daily for 5–7 days
  • Doxycycline 100 mg orally twice daily for 5–7 days
  • Azithromycin 500 mg daily for 3 days 4

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

Controlled Oxygen Therapy

• Target SpO₂ of 88–92% using controlled-delivery devices (Venturi mask 24–28% FiO₂ or nasal cannula 1–2 L/min) to correct hypoxemia while minimizing CO₂ retention. 1, 2, 5

• High-flow oxygen (>28% FiO₂ or >4 L/min) without arterial blood gas monitoring worsens hypercapnic respiratory failure and increases mortality by ~78%. 1

• Obtain arterial blood gas within 60 minutes of initiating oxygen to identify hypercapnia (PaCO₂ >45 mmHg) or acidosis (pH <7.35). 1, 2

• Repeat ABG at 30–60 minutes (or sooner if clinical deterioration occurs) to detect rising PaCO₂ or falling pH. 1

• If initial ABG shows normal pH and PaCO₂, the SpO₂ target may be increased to 94–98% only if the patient has no prior hypercapnic failure requiring NIV and their usual stable saturation is ≥94%. 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 >30 minutes after standard medical treatment. 1, 2

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by ~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 for consideration of invasive mechanical ventilation. 1

• Contraindications to NIV include altered mental status with inability to protect 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: 1, 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, renal or liver failure)
• Inability to care for self at home

Initial Investigations for Hospitalized Patients

• Arterial blood gas with documented FiO₂ 2
• Chest radiograph (alters management in 7–21% of cases by detecting pneumonia, pneumothorax, or pulmonary edema) 1, 2
• Complete blood count 2
• Comprehensive metabolic panel (urea, electrolytes) 2
• ECG within first 24 hours 2
• Initial FEV₁ and/or peak flow with serial monitoring 2

Discharge Planning and Follow-Up

• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce readmissions and improve quality of life; initiating rehabilitation during hospitalization increases mortality. 1, 2

• Initiate or 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. 1

• Measure FEV₁ before discharge to establish new baseline. 2

• Check arterial blood gases on room air in patients who presented with respiratory failure. 2

• 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. 3, 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. 3, 1, 2

• Never continue systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists. 3, 1, 2

• Never administer high-flow oxygen without arterial blood-gas monitoring, as this can worsen hypercapnic respiratory failure and increase mortality. 1

• Avoid sedatives and hypnotics, which can precipitate respiratory depression. 5

• Do not use diuretics unless there is clear evidence of peripheral edema and elevated jugular venous pressure. 3, 5

• Avoid humidification—there is no evidence it is necessary. 2