Management of COPD Exacerbations Reviewed

Pharmacotherapy, ventilation strategies, and other management issues regarding chronic obstructive pulmonary disease (COPD) exacerbations are reviewed in an article published in the March 1 issue of American Family Physician.

“In patients with known…COPD, exacerbations occur an average of 1.3 times per year,” writes Ann E. Evensen, MD, from University of Wisconsin School of Medicine and Public Health in Verona. “Exacerbations range in severity from transient declines in functional status to fatal events. In the United States, exacerbations have contributed to a 102 percent increase in COPD-related mortality from 1970 to 2002 (21.4 to 43.3 deaths per 100,000 persons).”

COPD Interventions

The goals of effective management of a COPD exacerbation are acute symptom relief as well as a reduced risk for subsequent exacerbations. Although COPD exacerbations are a key factor underlying the high mortality rates among patients with this condition, several interventions have been shown in randomized controlled trials to be effective.

Increasing the dosage of inhaled short-acting bronchodilators is recommended as the first step in outpatient treatment. In particular, the combination of ipratropium and albuterol is helpful for reducing dyspnea.

Patients with purulent sputum are likely to benefit from oral corticosteroids, and moderately or severely ill patients are likely to benefit from antibiotic therapy, which lowers the risk for treatment failure and death. In addition, antibiotics should be considered for patients with purulent sputum and for those with inadequate symptom relief with bronchodilator and corticosteroid therapy. Local patterns of antibiotic resistance and a patient-specific history of recent antibiotic use should guide initial antibiotic choice.

For exacerbations in hospitalized patients, treatment with regular doses of short-acting bronchodilators, continuous supplemental oxygen, antibiotics, and systemic corticosteroids is recommended. Patients with worsening acidosis or hypoxemia should receive noninvasive positive pressure ventilation or invasive mechanical ventilation.

Key Clinical Recommendations

Key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

• Noninvasive positive pressure ventilation improves respiratory acidosis while reducing respiratory rate, breathlessness, need for intubation, mortality rate, and length of hospital stay (level of evidence, A).
• In patients with COPD, inhaled bronchodilators (beta-agonists, alone or in combination with anticholinergic agents) reduce dyspnea and improve exercise tolerance (level of evidence, A).
• In patients with COPD, short courses of systemic corticosteroids prolong the time to subsequent exacerbation, reduce the rate of treatment failure, reduce length of hospitalization, and improve forced expiratory volume in 1 second and hypoxemia (level of evidence, A).
• Compared with high-dosage corticosteroid regimens, low-dosage regimens are not inferior in reducing the risk for treatment failure in patients with COPD (level of evidence, B).
• Compared with intravenous prednisolone, oral prednisolone is equivalent in lowering the risk for treatment failure in patients with COPD (level of evidence, B).
• Oral corticosteroids are bioavailable, inexpensive, and convenient, and are therefore recommended in patients who can safely swallow and absorb them (level of evidence, B).
• Patients with moderate or severe COPD exacerbations should be treated with antibiotics, especially in patients with increased sputum purulence or who need to be hospitalized (level of evidence, B).
• Symptoms, such as presence of purulent sputum; recent use of antibiotics; and local patterns of microbial resistance should help determine the choice of antibiotic in patients with COPD (level of evidence, C). Evidence is limited that broad-spectrum antibiotics are more effective than narrow-spectrum antibiotics.
• In patients with COPD, smoking cessation lowers the mortality rate and likelihood of subsequent exacerbations (level of evidence, A).
• In severely ill patients with COPD, long-term oxygen therapy reduces the risk for hospitalization and duration of hospitalization (level of evidence, B).

“To qualify for discharge, a patient should have stable clinical symptoms and a stable or improving arterial partial pressure of oxygen of more than 60 mm Hg for at least 12 hours [and] not require albuterol more often than every four hours,” Dr. Evensen writes.

“If the patient is stable and can use a metered dose inhaler, there is no benefit to using nebulized bronchodilators. Patient education may improve the response to future exacerbations; suggested topics include a general overview of COPD, available medical treatments, nutrition, advance directives, and advice about when to seek medical help.”

Dr. Evensen has disclosed no relevant financial relationships.

Am Fam Physician. 2010;81:607-613. Abstract

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