Management of COPD Exacerbations

Assessment and Diagnosis

The European Respiratory Society recommends that COPD exacerbation assessment should consider severity of underlying COPD, presence of comorbidities, and history of previous exacerbations 1
Physical examination should evaluate the effect on hemodynamic and respiratory systems, as suggested by the European Respiratory Society 2
Arterial blood gases should be monitored in severe exacerbations for PaO2, PaCO2, and pH, according to the European Respiratory Society 1

The European Respiratory Society recommends the use of short-acting β-agonists (salbutamol/albuterol, terbutaline) and/or ipratropium via MDI with spacer or nebulizer for outpatient treatment of COPD exacerbations 1
The European Respiratory Society suggests considering adding long-acting bronchodilator if patient is not already using one for outpatient treatment of COPD exacerbations 1
The European Respiratory Society recommends prednisone 30-40 mg orally daily for 5-7 days for outpatient treatment of COPD exacerbations 1
The European Respiratory Society recommends initiating antibiotics if patient has altered sputum characteristics (purulence and/or increased volume) for outpatient treatment of COPD exacerbations 1
The European Respiratory Society suggests first-line options of amoxicillin/ampicillin, cephalosporins, doxycycline, macrolides for outpatient treatment of COPD exacerbations 1
The European Respiratory Society recommends supplemental oxygen if saturation <90%, target PaO2 >60 mmHg or SpO2 >90% for hospitalized patient treatment of COPD exacerbations 1, 3
The European Respiratory Society suggests considering non-invasive ventilation (NIV) for patients with respiratory acidosis (pH <7.26) for intensive care unit treatment of COPD exacerbations 1, 4

The European Respiratory Society recommends hospitalization for marked increase in intensity of symptoms (severe dyspnea) 5
The European Respiratory Society suggests hospitalization for severe underlying COPD 1
The European Respiratory Society recommends hospitalization for onset of new physical signs (cyanosis, peripheral edema) 5
The European Respiratory Society suggests hospitalization for failure to respond to initial medical management 5
The European Respiratory Society recommends hospitalization for significant comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/liver failure) 5

The European Respiratory Society recommends ICU admission for impending or actual respiratory failure 1
The European Respiratory Society suggests ICU admission for presence of other end-organ dysfunction (shock, renal, liver, or neurological disturbance) 1
The European Respiratory Society recommends ICU admission for hemodynamic instability 1

The European Respiratory Society suggests that methylxanthines (aminophylline) should only be considered if patient is not responding to first-line treatments 4
The European Respiratory Society recommends against the use of chest physiotherapy in acute exacerbations of COPD 4
The European Respiratory Society suggests that diuretics should only be used if there is peripheral edema and raised jugular venous pressure 4
The European Respiratory Society recommends that when using oxygen therapy, prevention of tissue hypoxia takes precedence over CO2 retention concerns 3

The European Respiratory Society recommends review after an acute exacerbation to assess response to treatment 6
The European Respiratory Society suggests considering pulmonary rehabilitation within 3 weeks after hospital discharge 7, 8

The American Academy of Family Physicians recommends that short-acting bronchodilators are the cornerstone of acute treatment and should be initiated immediately for patients with COPD exacerbation 9

The European Respiratory Society and American Thoracic Society guideline recommends that oral corticosteroids are preferred over intravenous in hospitalized patients with COPD exacerbation 10
The American Academy of Family Physicians and European Respiratory Society guideline emphasizes that a 5-7 day course of systemic corticosteroids is sufficient, and longer durations increase adverse effects without improving outcomes 9, 10

The European Respiratory Society identifies common pathogens for COPD exacerbation as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 11

The European Respiratory Society and American Thoracic Society guideline recommends initiating pulmonary rehabilitation within 3 weeks after hospital discharge for patients with COPD exacerbation, but not during hospitalization itself 10
The European Respiratory Society guideline supports early initiation of pulmonary rehabilitation after discharge to improve outcomes, and also recommends considering home-based management programs for appropriate patients 10