What is the treatment for a patient with a history of aortic valve replacement, Chronic Obstructive Pulmonary Disease (COPD), diabetes, and pulmonary emphysema, now experiencing a COPD exacerbation?

From the Guidelines

For a patient with a history of aortic valve replacement, COPD, diabetes, pulmonary emphysema who is now experiencing a COPD exacerbation, I recommend a comprehensive treatment approach that prioritizes morbidity, mortality, and quality of life. The immediate management should include a short-acting bronchodilator such as albuterol (2-4 puffs every 4-6 hours as needed) and ipratropium bromide (2 puffs four times daily) to help alleviate bronchospasm and improve lung function 1.

• Systemic corticosteroids, typically prednisone 40mg daily for 5 days, are essential in reducing airway inflammation and improving symptoms, as evidenced by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.
• A course of antibiotics, such as azithromycin 500mg on day 1 followed by 250mg daily for 4 more days, or doxycycline 100mg twice daily for 5-7 days, is often warranted, especially if there are signs of infection like increased sputum purulence, as recommended by the American Academy of Family Physicians (AAFP) 1.
• Supplemental oxygen should be provided to maintain oxygen saturation above 88-90% to prevent hypoxemia and its consequences. For this patient, careful monitoring is crucial due to their cardiac history and multiple comorbidities.
• The diabetes management may need adjustment during steroid therapy, with more frequent blood glucose monitoring to prevent hyperglycemia. After the acute phase, optimizing maintenance therapy with long-acting bronchodilators and possibly inhaled corticosteroids will be important to prevent future exacerbations, as outlined in the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.
• Pulmonary rehabilitation should be considered once the patient stabilizes to improve exercise capacity and quality of life, which is a key aspect of managing COPD and reducing morbidity and mortality.

From the FDA Drug Label

Roflumilast tablet is indicated as a treatment to reduce the risk of COPD exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations. The patient has COPD exacerbation, severe COPD, chronic bronchitis, and pulmonary emphysema. Given the patient's condition, roflumilast (PO) may be considered as a treatment option to reduce the risk of COPD exacerbations 2.

• The patient's aortic valve replacement and diabetic condition are not directly relevant to the treatment of COPD exacerbations with roflumilast (PO).
• Roflumilast (PO) has been shown to significantly reduce the rate of moderate or severe exacerbations in patients with severe COPD associated with chronic bronchitis 2.

From the Research

Treatment for COPD Exacerbation

• The treatment for COPD exacerbation includes an increase in bronchodilators, chest physiotherapy, and antibiotics if sputum is frankly purulent 3.
• Systemic corticosteroids should not be systematic, with a recommended dose of 0.5 mg/kg on a short course (5-7 days) 3.
• Non-invasive ventilation is considered for patients with persistent hypercapnia despite optimal medical management 3.

Use of Nebulized Corticosteroids

• Nebulized corticosteroids, such as high-dose nebulized budesonide, can be an acceptable alternative to systemic corticosteroids in hospitalized patients with COPD exacerbations who are not critically ill 4.
• High-dose nebulized budesonide was found to be noninferior to systemic corticosteroids in terms of change in FEV1 and PaCO2, but inferior in terms of PaO2 changes 4.
• Nebulized corticosteroids may also reduce the frequency of hyperglycemia compared to systemic corticosteroids 4.

Pharmacologic Management of COPD

• The American Thoracic Society recommends the use of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance 5.
• Triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA may be considered for patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year 5.
• ICS withdrawal may be considered for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year 5.

Nebulized Therapies in COPD

• Nebulized therapies can provide an alternative administration route for patients with COPD who have challenges with handheld inhalers, such as cognitive, neuromuscular, or ventilatory impairments 6.
• Recent updates in nebulized therapies include the approval of two nebulized long-acting muscarinic antagonists, which add to the extensive range of nebulized therapies in COPD 6.
• Nebulized therapy may be a useful treatment option in the management of certain patient populations with COPD, particularly those with severe disease and frequent exacerbations 7.