Management of 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 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
Initial Assessment and Severity Classification
Classify the exacerbation into three categories that determine treatment location and intensity 2, 1:
- Mild exacerbation: Treat outpatient with short-acting bronchodilators alone 2, 1
- Moderate exacerbation: Treat outpatient with short-acting bronchodilators plus antibiotics and/or oral corticosteroids 2, 1
- Severe exacerbation: Requires hospitalization or emergency department evaluation, often with acute respiratory failure 2, 1
Hospitalization criteria include any of the following 1:
- Marked increase in dyspnea unresponsive to outpatient therapy
- Respiratory rate >30 breaths/min
- Inability to eat or sleep due to respiratory symptoms
- New or worsening hypoxemia (SpO₂ <90% on room air)
- Altered mental status or loss of alertness
- Inability to care for self at home
- High-risk comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes)
Oxygen Therapy
Target SpO₂ of 88–92% using controlled-delivery devices such as a Venturi mask (24–28% FiO₂) or nasal cannula (1–2 L/min) 1. High-flow oxygen (>28% FiO₂ or >4 L/min) without arterial 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. Repeat ABG at 30–60 minutes if the patient deteriorates clinically or if initial pH is <7.35 1.
If initial ABG shows normal pH and PaCO₂, the saturation 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.
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; this combination provides superior bronchodilation lasting 4–6 hours compared with either agent alone 2, 1. For patients able to coordinate inhalation, metered-dose inhalers with a spacer are equally effective 1.
Power nebulizers with compressed air, not oxygen, when PaCO₂ is elevated or respiratory acidosis is present, and provide supplemental oxygen via a separate nasal cannula 1.
Never use intravenous methylxanthines (theophylline/aminophylline) because they increase adverse effects without clinical benefit 2, 1.
Systemic Corticosteroid Protocol
Give oral prednisone 30–40 mg once daily for exactly 5 days starting immediately at 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 oral intake is impossible 1.
The 5-day regimen improves lung function and oxygenation, shortens recovery time and hospital stay, reduces treatment failure by over 50%, and lowers 30-day rehospitalization risk 2, 1.
Do not extend systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists 1.
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) 2, 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) include 2, 1:
- Amoxicillin-clavulanate 875/125 mg orally twice daily
- Doxycycline 100 mg orally twice daily
- Macrolides (azithromycin or clarithromycin)
The most common causative organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 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 2, 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% 2, 1.
Transfer to ICU if pH remains <7.26 despite NIV 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.
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 2, 1.
Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) before discharge 2, 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. Provide smoking cessation counseling with nicotine replacement therapy and behavioral support for current smokers 1.
Common Pitfalls to Avoid
- 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 in acute exacerbations—they add toxicity without benefit 2, 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, as this can worsen hypercapnic respiratory failure and increase mortality 1
- Never power nebulizers with oxygen in hypercapnic patients; use compressed air and provide supplemental oxygen via a separate nasal cannula 1