Management of Acute Exacerbations of COPD

antibiotics recommended ONLY for severe exacerbations of chronic obstructive pulmonary disease (COPD)
start with narrow-spectrum agent – amoxicillin, doxycycline, trimethoprim/sulfamethoxazole
limit broad-spectrum agents to patients likely to have resistant organism – nosocomial infection, recent antibiotic use
limit use of systemic corticosteroids to 2 weeks
longer courses not more effective
watch for hyperglycemia, especially in patients with diabetes
bronchodilators
inhaled beta-agonists and ipratropium equally effective
use ipratropium first since better tolerated
use combination after maximizing dose of initial bronchodilator
oxygen if needed to maintain oxygen saturation at least 90%
strongly encourage smoking cessation
avoid environmental triggers
influenza and pneumococcal vaccination



Recommendation 1: In patients with respiratory symptoms, particularly dyspnea, spirometry should be performed to diagnose airflow obstruction. Spirometry should not be used to screen for airflow obstruction in asymptomatic individuals. (Grade: strong recommendation, moderate-quality evidence.)

Recommendation 2: Treatment for stable chronic obstructive pulmonary disease (COPD) should be reserved for patients who have respiratory symptoms and FEV1 less than 60% predicted, as documented by spirometry. (Grade: strong recommendation, moderate-quality evidence.)

Recommendation 3: Clinicians should prescribe 1 of the following maintenance monotherapies for symptomatic patients with COPD and FEV1 less than 60% predicted: long-acting inhaled β-agonists, long-acting inhaled anticholinergics, or inhaled corticosteroids. (Grade: strong recommendation, high-quality evidence.)

Recommendation 4: Clinicians may consider combination inhaled therapies for symptomatic patients with COPD and FEV1 less than 60% predicted. (Grade: weak recommendation, moderate-quality evidence.)

Recommendation 5: Clinicians should prescribe oxygen therapy in patients with COPD and resting hypoxemia (Pao2 ≤55 mm Hg). (Grade: strong recommendation, moderate-quality evidence.)

Recommendation 6: Clinicians should consider prescribing pulmonary rehabilitation in symptomatic individuals with COPD who have an FEV1 less than 50% predicted. (Grade: weak recommendation, moderate-quality evidence.)