Acute Exacerbations of COPD (AECOPD) negatively impact health status and disease progression.

More than 80% of exacerbations are managed on an outpatient basis with pharmacological therapies including bronchodilators, corticosteroids, and antibiotics.

Drug Treatments

Oxygen

• Titrate oxygen saturation to 88-92%.
• Avoid overoxygenation.

Bronchodilators

• Short-acting beta2-agonists, with or without short-acting anticholinergics.
• No difference between both or their combination.
• No difference in clinical outcomes between inhaled use with a spacer and nebulized administration of these agents.

Corticosteroids

• Improve lung function, oxygenation, risk of early relapse, treatment failure, and the length of hospitalization.
• Duration: 5-7 days.
• Oral is equivalent to intravenous
• Choice based on patient´s clinical condition.

Antibiotics

• Recommended for patients with:
  • all three cardinal symptoms:
    • increase in dyspnea,
    • sputum volume, and
    • sputum purulence;
  • two cardinal symptoms, if increased purulence of sputum is a symptom;
  • require mechanical ventilation (invasive or noninvasive).
• Strong benefit among patients admitted to ICU.
• Duration: 5-7 days.
• Adjust to local antibiogram.

• UK National Institute for Health and Care Excellence (NICE) Guidelines 2019
  • Oral
    • Amoxicillin 500 mg TID.
    • Doxycycline 200 mg 1st day then 100 mg/day for total 5 days (note dosage).
    • Clarithromycin 500 mg BID.
    • If higher risk complications: Clavulin 500/125 mg TID 5 days or Septra DS 1 Tab BID 5 days.
  • IV (can’t take po/severely unwell)
    • Amoxicillin 500 mg TID.
    • Piperacillin/tazobactam 4.5 G TID.

Magnesium Sulfate

• Role remains uncertain.

Methylxanthines

• Not routinely recommended.

Non-Drug Treatments

Non-Invasive Ventilation (NIV)

First-line in patients admitted with acute hypercapnic respiratory failure:

• Improves gas exchange, work of breathing, mortality and intubation rate.
• BiPAP is preferred to CPAP.

Indications

• Respiratory rate of >28 breaths/min.
• Signs of respiratory fatigue or increased work of breathing.
• PaCO2 >45mmHg with a pH <7.35.
• Persistent hypoxemia.

Contraindications

• Absolute
  • Need endotracheal intubation.
  • Decreased level of consciousness.
  • Excess respiratory secretions.
  • Risk of vomiting and aspiration.
  • Inability to tolerate.
  • Unable to obtain a seal (craniofacial abnormalities, beard).
• Relative
  • Haemodynamic instability.
  • Severe hypoxia and/or hypercapnia.

NIV failure

• Progressive respiratory distress or rising respiratory rate.
• Decreasing level of consciousness.
• Haemodynamic instability.
• Worsening pH, PCO2, PO2.
• Worsening PaO2/FiO2 ratio.

Indications for Mechanical Ventilation

• NIV contraindication or failure.
• Respiratory or cardiac arrest.
• Worsening respiratory fatigue.
• Decreased level of consciousness.
• Hemodynamic instability.
• Persistent hypoxemia.

Delayed Sequence Intubation – increasingly used

• To optimize oxygenation conditions prior to intubation.
• Ketamine 0.5-1 mg/kg.
• Dexmedetomidine.

Rapid Sequence Intubation

• Propofol or Ketamine are recommended.
• No difference in muscle relaxant:
  • Succinylcholine 1.5 mg/kg.
  • Rocuronium 1 mg/kg.

• Severe symptoms at rest or with walk test.
• Oxygen saturation < 89%.
• Altered mental status.
• Acute respiratory failure.
• Failure to respond to medical treatment.
• Significant comorbidities.
• Insufficient home support.

Patients treated as outpatients should receive:

Education

• Inhaler technique.
• Use of a spacer.
• Smoking cessation assistance.
• Vaccinations.
• Strategies to prevent further exacerbations.

Medical management

• Short-acting inhaled beta-2 agonists, with or without short-acting anticholinergics.
• Corticosteroid short course.
• Antibiotics  (patients with a change in their sputum).
• Long-acting inhaled bronchodilators with or without inhaled corticosteroids.

Scheduled follow-up

1. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2019 


   
   

2. Suau SJ, et al. Management of Acute Exacerbation of Asthma and Chronic Obstructive Pulmonary Disease in the Emergency Department. Emerg Med Clin North Am. 2016 Feb;34(1):15-37.

   
   

3. Holden V, et al. Diagnosis and Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Emerg Med Pract. 2017 Oct;19(10):1-24.

    

   
   

4. Wedzicha JA Ers Co-Chair, et al. Management of COPD Exacerbations: A European Respiratory Society/American Thoracic Society Guideline. Eur Respir J. 2017 Mar 15;49(3). pii: 1600791.

    

   
   

5. Cochrane Database

    

   
   

6. BCGuidelines.ca – COPD