More than 80% of AECOPD can be managed on an outpatient basis with standard treatment of bronchodilators, oral corticosteroids, and antibiotics.37 Several factors warrant referral to a local emergency department and/or hospital admission: severe symptoms, heart failure, acute respiratory failure, onset of new physical signs, failure of exacerbation to respond to initial medical management, presence of serious comorbidities, and inadequate home support.38
Inhaled SABAs (eg, albuterol, levalbuterol) are the mainstay of therapy for AECOPD because of their rapid onset of action and efficacy in producing bronchodilation. These medications may be administered via a nebulizer or MDI with a spacer device and may be combined with a SAMA (eg, ipratropium). Clinicians often prefer nebulized therapy on the presumption of more reliable delivery of drug to the airway.37
For patients who continue to have frequent exacerbations despite optimal therapy with bronchodilators and anti-inflammatory agents, antibiotic prophylaxis has been considered and debated. Studies have shown that macrolides are most effective as they have anti-inflammatory as well as antibacterial effects; azithromycin 250 mg/d or 500 mg 3 times per week or erythromycin 500 mg twice daily has been shown to reduce the risk of exacerbations.39-41 However, the development of hearing loss and the potential development of antibiotic resistance are key issues of concern. Clinicians therefore need to weigh the benefits vs the risks associated with antibiotic treatment for AECOPD.39-41
Short-term oxygen therapy is recommended for patients hospitalized with acute exacerbations of chronic bronchitis, and long-term oxygen therapy is recommended for patients with stable, very severe COPD who remain hypoxemic at discharge. Continuous oxygen is generally recommended for those whose PaO2 is ≤55 mm Hg (normal 90-100 mm Hg) or those whose oxygen saturation levels are ≤88% (normal = >95%).
In the treatment of AECOPD, systemic corticosteroids have been shown to reduce length of hospital stay, provide earlier improvement in lung function and symptoms, and reduce the risk of treatment failure or relapse. A dosage of prednisone 40 mg/d for 5 days is recommended.42 Occasionally, patients may benefit from a higher dose or a longer course depending on the severity of the exacerbation and response to prior courses of glucocorticoids.
Oral Phosphodiesterase-4 Inhibitor
Roflumilast is an oral phosphodiesterase-4 inhibitor that is indicated for maintenance treatment as an add-on to bronchodilator therapy for adults with severe COPD associated with chronic bronchitis and a history of frequent exacerbations. Results of the 1-year REACT study showed that in symptomatic patients with severe COPD and a history of exacerbations, roflumilast significantly reduced the risk of severe exacerbations in those already receiving an ICS-LABA fixed combination and a LAMA (tiotropium) as background treatment.39
Referral for Hospitalization
Impending respiratory failure may manifest with use of accessory muscles, paradoxical chest wall/abdominal movements (chest and abdominal motion are asynchronous with respiration), worsening or new onset of central cyanosis, development of peripheral edema, and hemodynamic instability. With these severe respiratory findings, transferring the patient to the closest emergency department is necessary for more intense management.35,37
A combination of chronic bronchitis, emphysema, and hyperreactive airway disease, COPD requires a precise medical regimen that patients need to fully comprehend to avoid exacerbations. Acute exacerbations often require hospitalization and result in high mortality rates. Primary care clinicians are on the front lines caring for patients with COPD and as such, should educate them regarding the disease process, medication regimen, and nonpharmacologic treatments. They also should assess patients with acute exacerbations to determine the need for hospitalization.
Theresa Capriotti, DO, MSN, CRNP, is a clinical professor and Dana Galgano, BSN, and Lynne Kelley, BSN, are students at the ML Fitzpatrick College of Nursing at Villanova University in Villanova, Pennsylvania.
1. Murphy SL, Xu J, Kochanek KD, Curtin SC, Arias, E. Deaths: final data for 2015. Natl Vital Stat Rep. 2017;66(6):1-75.
2. Ma J, Ward EM, Siegel RL, Jemal A. Temporal trends in mortality in the United States, 1969-2013. JAMA. 2015;314(16):1731-1939.
3. Health, United States, 2015: with special feature on racial and ethnic health disparities. Hyattsville, MD: National Center for Health Statistics; 2016.
4. Ford ES, Croft JB, Mannino DM, Wheaton AG, Zhang X, Giles WH. COPD surveillance—United States, 1999-2011. Chest, 2013;144(1):284-305.
5. Wheaton AG, Cunningham TJ, Ford ES, Croft JB. Employment and activity limitations among adults with chronic obstructive pulmonary disease–United States, 2013. MMWR Morb Mortal Wkly Rep.2015;64(11):289-295.
6. Kosacz NM, Punturieri A, Crozton TL, et al. Chronic obstructive pulmonary disease among adults — United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(46):938-943.
7. Chronic obstructive pulmonary disease (COPD): basics about COPD. Centers for Disease Control and Prevention website. https://www.cdc.gov/copd/basics-about.html#ref1. Updated June 5, 2018. Accessed June 6, 2019.
8. Berg K, Wright JL. The pathology of chronic obstructive pulmonary disease: progress in the 20th and 21st centuries. Arch Pathol Lab Med. 2016;140(12):1423-1428.
9. Blanco I, Piccari L, Barberà JA. Pulmonary vasculature in COPD: the silent component. Respirology. 2016;21(6):984-994.
10. Decramer M, Janssens W, Miravitlles M. Chronic obstructive pulmonary disease. Lancet. 2012;379(9823):1341-1351.
11. Brusselle GG, Maes T, Bracke KR. Eosinophils in the spotlight: eosinophilic airway inflammation in nonallergic asthma. Nat Med. 2013;19(8):977-979.
12. Gentry S, Gentry B. Chronic obstructive pulmonary disease: diagnosis and management. Am Fam Physician. 2017;95(7):433-441.
13. Global Initiative for Chronic Obstructive Lung Disease. Pocket guide to COPD diagnosis, management, and prevention: a guide for health care professionals. Global Initiative for Chronic Obstructive Lung Disease, Inc. https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-POCKET-GUIDE-DRAFT-v1.7-14Nov2018-WMS.pdf. Published 2019. Accessed June 6, 2019.
14. Ebbert JO, Hatsukami DK, Croghan IT, et al. Combination varenicline and bupropion SR for tobacco-dependence treatment in cigarette smokers: a randomized trial. JAMA. 2014;311(2):155-163.
15. Pavlov N, Haynes AG, Stucki A, Jüni P, Ott SR. Long-term oxygen therapy in COPD patients: population-based cohort study on mortality. Int J Chron Obstruct Pulmon Dis. 2018;12:979-988.
16. DeBellis HF, Fetterman JW Jr. Enteral nutrition in the chronic obstructive pulmonary disease (COPD) patient. J Pharm Pract. 2012;25(6):583-585.
17. American Lung Association. 2018. Lung Health & Diseases: Nutrition and COPD. American Lung Association website. https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/living-with-copd/nutrition.html. Updated March 13, 2018. Accessed June 6, 2019.
18. Rawal G, Yadav S. Nutrition in chronic obstructive pulmonary disease: a review. J Transl Int Med. 2015;3(4):151-154.
19. O’Donnell DE, Gebke KB. Activity restriction in mild COPD: a challenging clinical problem. Int J Chron Obstruct Pulmon Dis. 2014;9:577-588.
20. Egan C, Deering BM, Blake C, et al. Short term and long term effects of pulmonary rehabilitation on physical activity in COPD. Respir Med. 2012;106(12):1671-1679.
21. Campos-Outcalt D. Pneumococcal vaccines for older adults: getting the timing right. J Fam Pract. 2014;63(12):730-733.
22. Pesek R, Lockey R. Vaccination of adults with asthma and COPD. Allergy. 2011;66(1):25-31.
23. Qureshi H, Sharafkhaneh A, Hanania NA. Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. Ther Adv Chronic Dis. 2014;5(5): 212-227.
24. Marchetti N, Criner GJ. Surgical approaches to treating emphysema: lung volume reduction surgery, bullectomy, and lung transplantation. Semin Respir Crit Care Med. 2015;36(4):592-608.
25. Simon M, Harbaum L, Oqueka T, Kluge S, Klose H. Endoscopic lung volume reduction coil treatment in patients with very low FEV1: an observational study. Ther Adv Respir Dis. 2018;12:1753466618760133.
26. Yusen RD, Christie JD, Edwards LB; International Society for Heart and Lung Transplantation. The registry of the International Society for Heart and Lung Transplantation: Thirtieth Adult Lung and Heart-Lung Transplant Report—2013; focus theme: age. J Heart Lung Transplant. 2013;32(10):965-978.
27. Ferguson GT, Make B. Management of stable chronic obstructive pulmonary disease. UpToDate website. https://www.uptodate.com/contents/management-of-stable-chronic-obstructive-pulmonary-disease. Updated January 16, 2019. Accessed June 13, 2019.
28. Lavorini F. Inhaled drug delivery in the hands of the patient. J Aerosol Med Pulm Drug Deliv. 2014;27(6):414-418.
29. Taffet GE, Donohue JF, Altman PR. Considerations for managing chronic obstructive pulmonary disease in the elderly. Clin Interv Aging. 2014;9:23-30.
30. Togger DA, Brenner PS. Metered dose inhalers. Am J Nurs. 2001;101(10):26-32.
31. Tashkin DP. A review of nebulized drug delivery in COPD. Int J Chron Obstruct Pulmon Dis. 2016;11:2585-2596.
32. Miravitlles M, Anzueto A. Role of infection in exacerbations of chronic obstructive pulmonary disease. Curr Opin Pulm Med. 2015;21(3):278-283.
33. Bartlett JG, Sethi S. Management of infection in exacerbations of chronic obstructive pulmonary disease. UpToDate website. https://www.uptodate.com/contents/management-of-infection-in-exacerbations-of-chronic-obstructive-pulmonary-disease. Updated November 19, 2018. Accessed June 6, 2019.
34. Çolak A, Yilmaz C, Toprak B, Aktoğu S. Procalcitonin and CRP as bBiomarkers in discrimination of community-acquired pneumonia and exacerbation of COPD. J Med Biochem. 2017;36(2):122-126.
35. Kaufman JS. Acute exacerbation of COPD. Nurse Pract. 2017;42(6):1-7.
36. Rangelov K, Sethi S. Role of infections. Clin Chest Med. 2014;35(1):87-100.
37. Stoller JK, Barnes PJ, Hollingsworth H. Management of exacerbations of chronic obstructive pulmonary disease. UpToDate website. https://www.uptodate.com/contents/management-of-exacerbations-of-chronic-obstructive-pulmonary-disease. Updated April 6, 2018. Accessed June 6, 2019.
38. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2018 Report). Global Initiative for Chronic Obstructive Lung Disease, Inc. https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf. Published 2018. Accessed June 6, 2019
39. Halpin DMG, Miravitlles M, Metzdorf N, Celli B. Impact and prevention of severe exacerbations of COPD: a review of the evidence. Int J Chron Obstruct Pulmon Dis. 2017;12:2891-2908.
40. Herath SC, Normansell R, Maisey S, Poole P. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev. 2018;10:CD009764.
41. Cui Y, Luo L, Li C, Chen P, Chen Y. Long-term macrolide treatment for the prevention of acute exacerbations in COPD: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis. 2018;13:3813-3829.
42. Magovern M, Sawyer S. Different durations of corticosteroid therapy for COPD exacerbations. Am Fam Physician. 2019;99(5):295-296.