5th January 2024

Management of Acute Exacerbation of COPD 

Exacerbation of COPD is an acute worsening of patient’s symptoms from a stable state. Multiple factors, including viral infections and smoking, can trigger an exacerbation.

Pharmacological management

Inhaled therapy

Both nebulisers and inhalers can be used as delivery systems for inhaled therapy during exacerbations of COPD. However, the choice of delivery system depends on patients’ ability to use the device, the available resources, and the dose of the drugs. In case of hypercapnia or acidosis, nebulisers should be driven by air rather than oxygen to prevent worsening hypercapnia.

Nebulisers should be switched to inhalers as soon as the patient’s condition is stabilised to facilitate earlier discharge from hospital.

Steroids

Systemic corticosteroids should be offered to patients with COPD exacerbation in the absence of significant contraindications. 30 mg of oral Prednisolone for 5 days is recommended.

Antibiotics

Antibiotics are recommended in case of bacterial exacerbation of COPD. Antibiotic choice should be guided by most recent sputum culture and susceptibilities whenever available. First-choice of empiric oral antibiotics is either Amoxicillin 500 mg three times a day for 5 days, Doxycycline 200 mg on first day, then 100 mg once a day for 5-day course in total or Clarithromycin 500 mg twice a day for 5 days.

If symptoms fail to improve after 2 to 3 days, an alternative first-choice antibiotics could be used. Second-choice antibiotics are co-amoxiclav 500/125 mg three times a day for 5 days, Co-trimoxazole 960 mg twice a day for 5 days or Levofloxacin 500 mg once a day for 5 days.

First-choice IV antibiotics are used if patient is severely unwell or unable to take oral medications as follows:

• Amoxicillin: 500 mg three times a day
• Co-amoxiclav: 1.2 g three times a day
• Clarithromycin: 500 mg twice a day
• Co-trimoxazole: 960 mg twice a day
• Piperacillin with tazobactam; 4.5 g three times a day

Theophylline and other methylxanthines

Intravenous Theophylline can be used in addition to other exacerbation management in case of inadequate response to nebulised bronchodilators. Theophylline level should be monitored within the first 24 hours.

Oxygen therapy

Arterial blood gases should be measured in all patients with COPD exacerbation, and Oxygen should be prescribed to maintain the oxygen saturation within the target range.

Non-invasive and invasive ventilation

NIV is the treatment of choice for type 2 respiratory failure that is persistent despite optimal medical therapy. When patients are started on NIV, ceiling of care should be clear in event of deterioration.

Invasive ventilation on intensive care units should be considered when necessary after careful assessment of suitability of patient for intensive care.

Respiratory physiotherapy

Chest physiotherapy aiming at clearing sputum should be considered in selected patients using positive expiratory pressure devices.

Respiratory stimulants

Doxapram is recommended only when NIV is unavailable or inadequate.

References

• Chronic Obstructive Pulmonary Disease (COPD) Differential Diagnoses [Internet]. Medscape.com. 2019. Available from: https://emedicine.medscape.com/article/297664-differential
• NICE. Recommendations | Chronic obstructive pulmonary disease in over 16s: diagnosis and management | Guidance | NICE [Internet]. Nice.org.uk. NICE; 2018. Available from: https://www.nice.org.uk/guidance/ng115/chapter/Recommendations#diagnosing-copd
• NICE Guideline. COPD (acute exacerbation): antimicrobial prescribing [Internet]. 2019. Available from: https://www.nice.org.uk/guidance/ng114/resources/guide-to-resources-pdf-6602624893