COPD Exacerbation

Consider a COPD exacerbation in a patient with known or likely COPD (e.g., long-term cigarette use, or coming from the developing world with long-term biofuel exposure while cooking) who has an acute worsening of dyspnea, cough, or sputum production.

The Management of COPD

Try to figure out what caused the exacerbation

(viral infection or bacterial pneumonia, smoke in the air from wildfires, etc.). If the patient smokes, advise them to stop.
Corticosteroids

40mg of prednisone daily for 5 days is standard. Sometimes critically ill patients receive a dose of 125mg IV methylprednisolone as their first dose of steroids.
Inhaled bronchodilators

A standard regimen would be "duonebs" (ipratropium and albuterol) four times daily with extra albuterol q2h PRN. The logic here is that ipratropium lasts about 6 hours, and albuterol lasts about 2 hours. For critically ill people, sometimes duonebs q4h is prescribed.
Antibiotics

If they need antibiotics for pneumonia, these will be sufficient. Otherwise, a standard regimen is 5 days of azithromycin or doxycycline. Independent of killing bacteria, azithromycin may have additional anti-inflammatory effects.
If the patient has acute hypercarbia,

(as evidenced by elevated CO2 and a low pH on their blood gas), start them on BiPAP.
If they have hypoxemic respiratory failure without hypercarbia,

start them on supplemental oxygen.
In severe cases,

sometimes patients need to be intubated (for example, if they have worsening severe acidemia and hypercarbia despite BiPAP).

Do NOT over-oxygenate these patients, especially those with chronic CO2 retention. Goal O2 can be somewhere around 88–94%.

Image credit: Eric Tanenbaum.

The Management of COPD

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