Management of Severe COPD Exacerbation

Initial Assessment and Monitoring

The British Thoracic Society recommends obtaining arterial blood gases immediately to assess oxygenation and acid-base status, noting the inspired oxygen concentration 1
The American Thoracic Society suggests monitoring oxygen saturation continuously with pulse oximetry 2
The European Respiratory Society recommends performing chest radiograph to rule out pneumonia or other complications, and completing blood count, urea and electrolytes, and ECG within the first 24 hours 3
The British Thoracic Society recommends recording initial FEV1 and/or peak flow and starting a serial peak flow chart 3

The American College of Chest Physicians recommends maintaining target oxygen saturation of 88-92% to avoid respiratory acidosis 1, 2
The British Thoracic Society suggests gradually increasing oxygen concentration until PaO2 is above 7.5 kPa if PaO2 is responding without pH deterioration 4
The European Respiratory Society recommends repeating arterial blood gas measurements within 60 minutes of starting oxygen therapy and if clinical situation deteriorates 3

The Global Initiative for Chronic Obstructive Lung Disease recommends continuing current albuterol (salbutamol) 20mg/hr continuous nebulization 4
The European Respiratory Society suggests adding ipratropium bromide 0.25-0.5 mg via nebulizer for severe exacerbations 4, 5
The American Thoracic Society recommends ensuring nebulizers are driven by compressed air if the patient has hypercapnia and/or respiratory acidosis 4

The European Respiratory Society recommends a dosing of 30-40 mg IV daily for 10-14 days of intravenous methylprednisolone (solumedrol) 5
The American College of Chest Physicians suggests considering transitioning to inhaled corticosteroids when appropriate before discharge 5

The Infectious Diseases Society of America recommends prescribing antibiotics based on local bacterial resistance patterns 4, 5
The British Thoracic Society suggests first-line options include amoxicillin or tetracycline unless used with poor response prior to admission 3
The European Respiratory Society recommends considering broad-spectrum cephalosporins or respiratory fluoroquinolones for more severe exacerbations 5, 3

The American College of Chest Physicians recommends considering intravenous methylxanthines (aminophylline 0.5 mg/kg/hour) by continuous infusion if patient is not responding to current therapy 4
The European Respiratory Society suggests monitoring blood levels daily if methylxanthines are used 4, 2
The British Thoracic Society recommends administering diuretics if there is peripheral edema and raised jugular venous pressure 4
The American Thoracic Society suggests considering prophylactic subcutaneous heparin for prevention of thromboembolism 4, 3

The British Thoracic Society recommends considering non-invasive ventilation (NIV) if respiratory acidosis persists (pH < 7.26) despite standard medical management 4, 6
The European Respiratory Society suggests NIV has been shown to reduce the need for intubation and length of hospital stay 6
The American Thoracic Society recommends avoiding NIV in patients with confusion or large volume of secretions 6

The American College of Chest Physicians recommends avoiding uncontrolled high-flow oxygen which may worsen hypercapnia 2
The European Respiratory Society suggests not continuing corticosteroids beyond 14 days unless specifically indicated 2
The American Thoracic Society recommends avoiding prolonged courses of antibiotics beyond 7 days 2
The British Thoracic Society suggests not using chest physiotherapy routinely as it is not recommended in acute COPD exacerbations 4

The American College of Chest Physicians recommends ensuring adequate support for home care 1
The European Respiratory Society suggests providing education on medication use and delivery devices 1
The British Thoracic Society recommends planning for follow-up within 4-6 weeks to reassess corticosteroid requirements 4