Acute COPD exacerbation: outpatient treatment

Managing an acute COPD exacerbation involves several decisions—but one stands out: can this patient be safely managed at home? This lesson walks you through outpatient treatment for mild and moderate COPD exacerbations—what to prescribe, when to add steroids or antibiotics, and when your patient requires hospitalization.

In this lesson from our COPD Essentials course you'll learn how to:

• Use short-acting bronchodilators to relieve symptoms of COPD exacerbations
• Prescribe oral glucocorticoids to improve recovery
• Identify when antibiotics are appropriate in COPD exacerbations
• Assess exacerbation severity to guide outpatient management
• Identify patients who require hospital-level care

Outpatient treatment of acute COPD exacerbations

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In this Medmastery lesson, we'll cover the outpatient management of mild and moderate COPD exacerbations. We'll also cover which patients will need to be sent to the emergency department. More than anything, the severity of an exacerbation dictates if the patient can be treated as an outpatient. More than 80% of exacerbations are managed on an outpatient basis. In this setting, the potential medication used for the management of exacerbations can include short-acting bronchodilators, oral glucocorticoids, and antibiotics.

Short-acting bronchodilators for COPD exacerbations

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Let's start with the short-acting bronchodilators which include albuterol and ipratropium. When delivering these medications, there is no significant benefit in using either a metered dose inhaler or a nebulizer. I personally prefer inhalers because they are more accessible and convenient, since the patient won't need an additional device or electricity source.

Oral glucocorticoids in acute COPD exacerbation treatment

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Glucocorticoids, namely prednisone, shorten recovery time, improve lung function, improve oxygenation, and improve treatment success. A dose of 40 mg a day for a maximum of five days is routine. When prescribing steroids, be aware that longer courses of steroids can be associated with increased risk of infection and mortality. Importantly, there's no difference between oral versus intravenous or intramuscular administration of steroids, but you will want to make sure that the patient can safely ingest the oral form before prescribing it. The sooner you start the steroid, the better, as it takes 6 to 12 hours for the steroids to take effect.

Recommendations for antibiotic use in COPD exacerbations

When to use antibiotics

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The use of antibiotics in COPD is controversial. There is evidence supporting the use of antibiotics in patients with signs of bacterial infection, like increased sputum purulence, which can appear as yellow or greenish in color. The problem is that the sputum color is not very reliable, and we likely over prescribe antibiotics which leads to downstream negative issues like resistance and side effects.

CRP-guided antibiotic use

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Two randomized studies showed a significant reduction in antibiotic prescription when their use was guided by the C-reactive protein, or CRP, levels in the blood. The downside is that the point-of-care testing for CRP is not often available in the outpatient setting.

GOLD recommendations for antibiotic treatment

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So the Global Initiative for Chronic Obstructive Lung Disease, or GOLD, recommends a three to five day course of antibiotics for patients presenting with increased shortness of breath, sputum volume, and purulence. The choice of antibiotics should be based on your local bacterial resistance pattern, but suitable antibiotics include amoxicillin with clavulanic acid, macrolides, doxycycline, or tetracycline.

Mild vs. moderate COPD exacerbations

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Assuming your patient is stable and is presenting with a mild exacerbation to an outpatient clinic, the mainstay of therapy is short-acting bronchodilators. In the outpatient setting, caring for a patient with moderate exacerbation can be tricky. If you feel that your patient is responding to short-acting bronchodilators and can continue therapy at home, they can be managed as an outpatient with the addition of a short course of oral steroids and possibly antibiotics.

When acute COPD exacerbations require hospital care

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On the other hand, if the patient is not responding or is unable to follow and maintain their medication schedule, they will need to be transferred to the emergency department or directly admitted to the hospital. Other indications for hospitalization include new oxygen requirement, new confusion, respiratory failure, presence of a serious comorbidity like heart failure, new cardiac dysrhythmia, or pulmonary embolism, the need for frequent short-acting beta-2 agonists. And if the patient does not have sufficient home and social support, they may need to be hospitalized as well.

Prognosis after severe COPD exacerbations

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Unfortunately, the long-term prognosis for patients that require hospitalization for a COPD exacerbation is poor, with a five year mortality rate of about 50% and a poorer quality of life. The independent factors that are associated with poor outcome include older age, presence of comorbidities like cancer or cardiovascular disease, low body mass index, and the need for long-term oxygen therapy after discharge.

Now you know how to manage COPD exacerbations in the outpatient setting. We'll discuss caring for the patient that you sent to the hospital in another Medmastery lesson.