Management of COPD Exacerbations

Initial Treatment

• The American Thoracic Society recommends that the initial treatment for a patient experiencing a COPD exacerbation should include short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, systemic corticosteroids, and antibiotics when indicated 1, 2
• Short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation 1, 2

Bronchodilator Therapy

• For moderate exacerbations, either a beta-agonist or an anticholinergic drug should be given via nebulizer 3
• For severe exacerbations, or if the response to either treatment alone is poor, both SABA and SAMA should be administered together 3, 4
• Nebulized bronchodilators should be given upon arrival and at 4-6 hourly intervals thereafter, but may be used more frequently if required 3

Systemic Corticosteroids

• Systemic glucocorticoids improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1, 2
• A dose of 40 mg prednisone per day for 5 days is recommended 1, 5
• Duration of therapy should not be more than 5-7 days 1, 2

Antibiotic Therapy

• Antibiotics should be given to patients with acute exacerbations who have three cardinal symptoms: increase in dyspnea, sputum volume, and sputum purulence 1, 2
• The recommended duration of antibiotic therapy is 5-7 days 1, 2
• First-line antibiotics include amoxicillin or tetracycline unless used with poor response prior to admission 3

Oxygen Therapy

• The aim of oxygen therapy is to achieve a PaO2 of at least 6.6 kPa or SpO2 ≥90% without causing respiratory acidosis 3, 4
• In patients with known COPD aged 50 years or older, initial FiO2 should not exceed 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known 3

Additional Considerations

• Noninvasive ventilation (NIV) should be considered for patients with acute respiratory failure, as it improves gas exchange, reduces work of breathing, decreases hospitalization duration, and improves survival 1, 2
• Initial investigations should include arterial blood gas analysis, chest radiograph, complete blood count, electrolytes, and ECG 3

Treatment Algorithm

• For all COPD exacerbations, start with short-acting bronchodilators and add systemic corticosteroids and antibiotics as indicated 1, 2
• For patients with purulent sputum or signs of infection, add appropriate antibiotics for 5-7 days 1, 2
• For hypoxemic patients, add controlled oxygen therapy to maintain SpO2 ≥90% 3, 4