Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)

Treatment options

Treatment: immediate

• Oxygen 28% via venturi mask if SpO₂ <88% until gases checked, then titrate according to arterial blood gases. Prescribe on HEPMA (hospital electronic prescribing system), or on a drug kardex if your area of practice does not have HEPMA. 
• Corticosteroids:
  • Prednisolone oral 25mg-40mg each morning for 5 days. If patient is unable to take oral treatment give:
  • Hydrocortisone IV 100mg immediately then review, and if there is a need to continue IV therapy, prescribe 50mg 6 hourly.
  • Note: If patient has suspected / confirmed COVID-19 and AECOPD, consider treatment with dexamethasone. See the COVID management guideline for dosing details.
• Bronchodilators:
  • Nebulisation should be with air. Supplementary oxygen via nasal cannula during nebulisation (1-6L/minute to maintain oxygen saturation 88-92%). Use a mouthpiece or close fitting mask to avoid risk of acute angle-closure glaucoma with ipratropium.
  • Salbutamol 2.5-5mg nebules four times daily (but can be given up to 2 hourly as needed)
  • Ipratropium 0.5mg nebules four times daily (add if poor response to salbutamol).
  • IV bronchodilators: aminophylline infusion may be considered if there is no response to nebulised therapy (dose administration and monitoring guidance see Appendices 2 and 3). N.B. The evidence for aminophylline in AECOPD is limited although individual patients may benefit. Discuss with senior doctors. Side effects include nausea, seizures and cardiac arrhythmias. 
• Non-invasive ventilation: If worsening respiratory acidosis or hypercapnia occurs, despite achieving target oxygen levels and adequate immediate therapy, ventilation may be indicated (see Non-invasive ventilation protocol in COPD). 
• Antibiotics:
  • Indicated in the presence of increased sputum purulence, raised inflammatory markers or focal radiological changes. They should be given orally unless there is a clinical reason for giving IV antibiotics. Send sputum for microscopy and culture. For antibiotic choice and course duration see lower respiratory tract infections treatment guideline
  • Note: Serious drug interactions with clarithromycin (see BNF Appendix 1) and QTc prolongation (see the Medicines Update Extra (MUE 08) Drug Induced QT Prolongation article at www.ggcmedicines.org.uk).  
• DVT Prophylaxis
• Physiotherapy: may be required for mucus plugging or dense consolidation present on x-ray. There is no evidence to support emergency call out.
• Mucolytic therapy: may be of symptomatic benefit in patients to aid sputum clearance. Prescribe acetylcysteine oral 600mg effervescent tablets once daily.

Prior to discharge

1. Stop oxygen when SpO₂ maintained >88% (unless on home oxygen). 
2. If still benefiting from nebulisers, consider early supported discharge (ESD). Home nebulisers should not be introduced as routine treatment immediately after acute exacerbation. 
3. Prednisolone oral 25mg-40mg each morning for 5 days, without dose tapering, will be suitable for most patients.
   N.B. There may be circumstances, however, where a more prolonged course or a stepped dose reduction is necessary. In patients who are oral steroid dependent, reduce the dose to the normal maintenance dose. If multiple recent courses of high dose oral steroids (e.g. prednisolone ≥ 40mg for 3 weeks within 3 months) or the patient is considered at risk of adrenal suppression, consider reducing dose directly to 10mg and discuss with respiratory or endocrine regarding weaning. Tapering of steroids from 40mg to 10mg is not recommended. If in doubt, discuss with senior. Long-term steroids are not indicated in patients with COPD.
4. Ensure inhaled medications optimised prior to discharge and appropriate inhaler technique (see the GGC COPD inhaler device guide). 
5. Consider referral for early supported discharge (ESD - respiratory nurse specialists). 
6. Consider referring for pulmonary rehabilitation (if MRC dyspnoea grade is ≥3 when stable if not attended in the last 2 years).
7. Smoking cessation advice, nicotine replacement and referral to smoking cessation services if appropriate (see Appendix 1).
8. Home oxygen is usually assessed as an outpatient when patients are stable for at least 6 weeks post exacerbation and non-smoking.