Management of COPD Exacerbation

Initial Evaluation

The British Thoracic Society recommends that urgent investigations should include measurement of arterial blood gases, chest radiography, full blood count, urea, electrolytes, and electrocardiogram 1, 2
If purulent sputum is present, it should be sent for culture, and if pneumonia is suspected, blood cultures are recommended 1

The goal of oxygen therapy is to achieve a PaO2 of at least 6.6 kPa (60 mmHg) without causing a drop in pH below 7.26 (due to an increase in PaCO2) 1, 2
In patients over 50 years old with a history of COPD, oxygen should not be administered at a FiO2 greater than 28% via a Venturi mask or 2 L/min via nasal cannulae until arterial blood gases are known 1, 2
Arterial blood gases should be checked within 60 minutes of starting oxygen therapy and within 60 minutes of any change in oxygen concentration 1, 2
A pH below 7.26 is predictive of a poor prognosis 1, 2

The American Thoracic Society recommends that short-acting beta-2 agonists, with or without short-acting anticholinergics, be used as initial bronchodilators 3
For moderate exacerbations, a beta-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) or an anticholinergic (ipratropium bromide 0.25-0.5 mg) should be administered 1, 2
For severe exacerbations or if the response to either treatment alone is poor, both may be administered 1, 2

The American Thoracic Society recommends that systemic corticosteroids improve lung function, oxygenation, and shorten recovery time 3
A 5-day course of prednisolone 30-40 mg/day (or 100 mg of hydrocortisone if oral route is not possible) is recommended 1, 2, 3

The American Thoracic Society recommends that antibiotics be prescribed when patients have an increase in dyspnea, increase in sputum volume, and increase in sputum purulence 3
Common antibiotics are generally adequate: amoxicillin or tetracycline are first-line choices, unless previously used with a poor response before admission 1, 2

The American Thoracic Society recommends that non-invasive ventilation (NIV) be the first mode of ventilation used in patients with COPD and acute respiratory failure who have no absolute contraindications 3
NIV improves gas exchange, reduces respiratory work and need for intubation, decreases hospital stay, and improves survival 3

If the patient does not respond to the above treatments, consider methylxanthines by continuous infusion (aminophylline 0.5 mg/kg per hour) 1, 2
However, methylxanthines are generally not recommended due to their increased side effect profile 3

An exacerbation of COPD is defined as an acute worsening of respiratory symptoms requiring additional therapy, with key symptoms including increased dyspnea, increased sputum volume, and increased sputum purulence 4, 5
Exacerbations are classified as mild, moderate, or severe, with severe exacerbations requiring hospitalization or emergency room visit 4, 5
The American Thoracic Society recommends assessing for signs of severe exacerbation, including severe dyspnea, use of accessory muscles, cyanosis, peripheral edema, and confusion, and evaluating for differential diagnoses including pneumonia, pneumothorax, heart failure, pulmonary embolism, lung cancer, and upper airway obstruction 6

The American College of Chest Physicians recommends short-acting inhaled β2-agonists with or without short-acting anticholinergics as the initial bronchodilators of choice, with the inhaled route preferred using metered-dose inhalers with spacers or nebulizers depending on patient ability 4, 5, 7
Systemic glucocorticoids, such as 40 mg prednisone daily for 5 days, improve lung function, oxygenation, and shorten recovery time, with oral administration equally effective to intravenous administration in most cases 5
Antibiotics should be prescribed when patients present with increased dyspnea, increased sputum volume, and increased sputum purulence, with first-line antibiotics including amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid for 5-7 days 5, 7, 8
The European Respiratory Society recommends providing controlled oxygen therapy to maintain PaO2 > 60 mmHg without causing respiratory acidosis, starting with low-flow oxygen until arterial blood gas results are available 7, 8

The American College of Chest Physicians recommends considering hospitalization for patients with marked increase in intensity of symptoms, severe underlying COPD, new physical signs, failure to respond to initial medical management, significant comorbidities, or insufficient home support 4, 5, 6, 7
Maintenance therapy with long-acting bronchodilators should be initiated before hospital discharge, and annual influenza vaccination and pneumococal vaccination as indicated 4, 7
Regular follow-up is necessary to monitor symptoms, exacerbations, and lung function, with consideration of pulmonary rehabilitation and smoking cessation counseling and support 4, 7, 8