What is the recommended inpatient management for an acute chronic obstructive pulmonary disease exacerbation?

Inpatient Management of Acute COPD Exacerbation

Immediate Oxygen Therapy

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

• Obtain arterial blood gas within 60 minutes of starting oxygen to detect hypercapnia (PaCO₂ > 45 mmHg) or acidosis (pH < 7.35). 1, 2, 3
• Repeat ABG at 30–60 minutes if clinical deterioration occurs or if initial pH < 7.35. 1
• High-flow oxygen (>28% FiO₂ or >4 L/min) without concurrent blood-gas monitoring worsens hypercapnic respiratory failure and increases mortality by approximately 78%. 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 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, 2, 3

• 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 at 1–2 L/min. 1
• Continue nebulized therapy for 24–48 hours until clinical improvement, then switch to metered-dose inhalers with spacer. 1
• Intravenous methylxanthines (theophylline/aminophylline) must never be used—they increase adverse effects without clinical benefit. 1, 2, 3

Systemic Corticosteroid Protocol

Give oral prednisone 30–40 mg once daily for exactly 5 days starting immediately upon admission. 1, 2, 3

• 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
• Corticosteroids improve lung function, oxygenation, shorten recovery time and hospital stay, and reduce treatment failure by over 50%. 1, 2
• Do not extend systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists. 1, 2, 3

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, 3

• This strategy reduces short-term mortality by approximately 77%, treatment failure by 53%, and sputum purulence by 44%. 1, 2
• First-line agents (selected according to local resistance patterns): amoxicillin-clavulanate 875/125 mg twice daily, doxycycline 100 mg twice daily, or macrolides (azithromycin or clarithromycin). 1, 2, 3
• 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, 3

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospital stay, and improves survival. 1, 2, 3
• Success rates in appropriately selected patients are 80–85%. 1, 3
• Transfer to ICU if pH remains <7.26 despite NIV. 1
• Contraindications to NIV: altered mental status with inability to protect airway, large-volume secretions, hemodynamic instability, or recent facial/upper-airway surgery. 1

Initial Diagnostic Workup

Obtain arterial blood gas, chest radiograph, complete blood count, comprehensive metabolic panel, and ECG on all hospitalized patients. 2, 3

• Chest radiograph alters management in 7–21% of cases by identifying pneumonia, pneumothorax, or pulmonary edema. 1
• Record initial FEV₁ and/or peak flow when feasible. 2, 3
• Send sputum for culture if purulent; consider blood cultures if pneumonia is suspected. 2, 3
• Absence of spirometric assessment and arterial blood-gas analysis during hospitalization is associated with higher rates of rehospitalization and mortality. 1

Hospitalization Criteria

Admit or evaluate in the emergency department if any of the following are present: 1, 2, 3

• 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 elevated jugular venous pressure are present; avoid aggressive diuresis that could compromise cardiac output. 1
• Administer prophylactic subcutaneous heparin for venous thromboembolism prevention in patients with acute-on-chronic respiratory failure. 1, 3
• Do not use chest physiotherapy—no evidence of benefit in acute COPD exacerbations. 1

Discharge Planning

Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce hospital readmissions and improve quality of life. 1, 2, 3

• Initiating rehabilitation during hospitalization increases mortality; post-discharge timing is protective. 1
• Initiate or optimize long-acting bronchodilator therapy (LAMA, LABA, or combinations) before discharge. 1, 3
• Do not step down from triple therapy (LAMA + LABA + ICS) during or immediately after an exacerbation—ICS withdrawal increases recurrent exacerbation risk. 1
• Verify proper inhaler technique 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. 2, 3

Critical 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 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, 3
• Never continue systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists. 1, 2, 3
• Never administer high-flow oxygen without arterial blood-gas monitoring—this can worsen hypercapnic respiratory failure and increase mortality. 1