Managing AECOPD

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

Bronchodilators

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

Antibiotics

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

Oxygen Therapy

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%).

Oral Corticosteroids

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

Related Articles

Conclusion

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.

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