What is the recommended immediate management of an acute exacerbation of chronic obstructive pulmonary disease?

Management of Acute Exacerbation of COPD

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 sputum volume. 1, 2

Initial Assessment and Oxygen Management

• Perform pulse oximetry immediately upon arrival and target SpO₂ of 88–92% using controlled-delivery devices (24–28% Venturi mask or 1–2 L/min nasal cannula) to prevent CO₂ retention and worsening respiratory acidosis. 1, 2

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

• If pH < 7.26 with rising PaCO₂ after initial therapy, prepare immediately for noninvasive ventilation. 1

• Never administer high-flow oxygen (>28% FiO₂ or >4 L/min) without arterial blood gas monitoring, as uncontrolled oxygen worsens hypercapnic respiratory failure and increases mortality by approximately 78%. 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 to either agent alone. 3, 1, 2

• 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

• Continue nebulized bronchodilators for 24–48 hours or until clinical improvement occurs, then transition to metered-dose inhalers with spacer. 3, 1

• For moderate exacerbations, either a β-agonist or anticholinergic alone may suffice; for severe exacerbations or poor response to monotherapy, use both agents together. 3, 2

• Avoid intravenous methylxanthines (theophylline/aminophylline) entirely—they increase adverse effects without providing clinical benefit in acute exacerbations. 1, 4

Systemic Corticosteroid Protocol

• Give oral prednisone 30–40 mg once daily for exactly 5 days starting immediately upon presentation; this short course is as effective as 14-day regimens while reducing cumulative steroid exposure by more than 50%. 1, 2

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

• This 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. 1, 2

• Do not extend systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists, to avoid unnecessary steroid-related adverse effects. 3, 1, 2

Antibiotic Therapy

• Prescribe antibiotics for 5–7 days when sputum purulence is present plus either increased dyspnea or increased sputum volume (two of three cardinal symptoms, with purulence required). 1, 2

• This strategy 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): amoxicillin-clavulanate 875/125 mg twice daily, doxycycline 100 mg twice daily, or macrolides (azithromycin 500 mg day 1 then 250 mg daily for 4 days, or clarithromycin). 1, 2, 5

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

• If the patient has all three cardinal symptoms (increased dyspnea, sputum volume, and purulence), antibiotics are strongly indicated. 2

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 treatment. 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

• 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; these patients require invasive mechanical ventilation. 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

Additional Supportive Measures

• Use diuretics only if peripheral edema and raised jugular venous pressure are present; avoid aggressive diuresis that could impair cardiac output. 3, 1

• Administer prophylactic subcutaneous heparin for venous thromboembolism prevention in patients with acute-on-chronic respiratory failure. 3, 1

• Do not use chest physiotherapy—there is no evidence of benefit in acute COPD exacerbations. 3, 1

• Obtain chest radiograph on all hospitalized patients to exclude pneumonia, pneumothorax, or pulmonary edema, as imaging alters management in 7–21% of cases. 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. 1

• 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 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. 3, 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 in acute exacerbations—they add toxicity without benefit. 1, 4

• 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