From the Guidelines
COPD exacerbations are typically classified into three severity stages: mild, moderate, and severe, with treatment approaches varying based on the stage to minimize morbidity, mortality, and improve quality of life. The classification and management of these stages are crucial for preventing the worsening of exacerbations and reducing the risk of lung function decline and mortality. According to the most recent and highest quality evidence available, as outlined in the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1, the stages are defined as follows:
- Mild exacerbations can be managed with increased use of short-acting bronchodilators.
- Moderate exacerbations require the addition of oral corticosteroids and possibly antibiotics if bacterial infection is suspected.
- Severe exacerbations necessitate hospitalization for intensive treatment, including intravenous corticosteroids, nebulized bronchodilators, supplemental oxygen, and possibly non-invasive ventilation if respiratory failure develops.
Key considerations in managing COPD exacerbations include the use of short-acting inhaled β2-agonists, with or without short-acting anticholinergics, as initial bronchodilators, and the initiation of maintenance therapy with long-acting bronchodilators as soon as possible before hospital discharge 1. Systemic corticosteroids are recommended to improve lung function, oxygenation, and shorten recovery time and hospitalization duration. Antibiotics should be used when indicated to shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration. Non-invasive ventilation (NIV) should be considered in patients with acute respiratory acidosis or those at risk of developing it, as it can prevent endotracheal intubation and invasive mechanical ventilation 1.
The goal of treatment is to minimize the negative impact of the current exacerbation and prevent subsequent events, with a focus on improving symptoms, lung function, and quality of life, while reducing morbidity and mortality. Early recognition and appropriate treatment based on severity stage are crucial to achieve these goals. Factors associated with an increased risk of acute exacerbations and/or severity of exacerbations include worse lung function, lower exercise capacity, chronic bronchitis, and specific findings on chest CT imaging, such as increased emphysema or airway wall thickness 1.
The most effective approach to managing COPD exacerbations involves a comprehensive strategy that includes classification of the exacerbation severity, appropriate pharmacological treatment, and consideration of non-invasive ventilation when necessary, all aimed at minimizing the impact on the patient's quality of life and reducing the risk of future exacerbations and mortality. This approach should be guided by the latest evidence and clinical guidelines, with a focus on individualizing treatment to the patient's specific needs and circumstances.
From the Research
COPD Exacerbation Stage
The stage of COPD exacerbation is crucial in determining the appropriate treatment and management plan. According to 2, exacerbations of chronic obstructive pulmonary disease (COPD) are associated with high rates of hospitalizations, costs, and morbidity.
Diagnosis and Severity
Comprehensive screening and diagnostic testing of patients at admission will enable an accurate diagnosis of COPD exacerbations, and severity, as well as other factors that may impact the length of hospital stay. The following are key points to consider:
- Comprehensive screening and diagnostic testing are essential for accurate diagnosis and severity assessment 2
- Pharmacotherapies may include short-acting bronchodilators, systemic corticosteroids, and antibiotics, depending on the exacerbation severity and cause 2
- Oxygen and/or ventilatory support may benefit patients with demonstrable hypoxemia 2
Treatment Options
Treatment options for COPD exacerbation include:
- Combination therapy with albuterol and ipratropium bromide, which has been shown to be more effective than either agent alone 3, 4, 5, 6
- The combination of ipratropium bromide and albuterol sulfate is more effective than albuterol base alone 5
- The combination of ipratropium and albuterol optimizes pulmonary function reversibility testing in patients with COPD 6
Management Plan
A management plan for COPD exacerbation should include:
- Appropriate maintenance therapy 2
- Counseling on medications, including inhalation devices 2
- Proactive discussion on smoking cessation and vaccinations 2
- Effective communication and follow-up, including transfer of discharge summaries to the primary care physician and scheduling of follow-up appointments 2