Table.
Treatment of acute exacerbations of COPD
| Disorder | Therapy | Strength of recommendation* | Comments |
|---|---|---|---|
| Bacterial infection of airways | Antibiotics | ++ | Benefits supported by R/PC and R/DB/PC trials,7, 24 especially for severe exacerbations |
| Airway inflammation | Corticosteroids | +++ | Benefits supported by R/DB/PC trials26†, 30, 31† may also decrease airway secretions |
| Bronchoconstriction | Aerosolised-adrenergic agonist | +++ | Metered-dose inhaler/spacer equal to wet nebuliser in R/DB trials;32, 33 β-adrenergic agonists may also enhance mucociliary clearance |
| Aerosolised ipratopium | +++ | Maximum effect same as β-adrenergic agonists but slower onset in R/DB trial32 | |
| Combined β-adrenergic agonist +ipratropium | + | Combination therapy more effective than single agents in stable COPD by R/DB/PC trials (see further reading), but no advantage over single agents in acute R/DB trial33 | |
| Theophylline+other bronchodilator | ·· | R/DB/PC trial shows no advantage in adding theophylline to otherwise standard therapy34† | |
| Secretions | Stop smoking | +++ | By consensus, generally recommended2, 3, 6 |
| Expectorants, iodides, DNase | ·· | By consensus, no proven value in acute setting2, 3 | |
| Hydration in excess of euvolaemia | ·· | By consensus, no proven value in acute setting2, 3 | |
| Chest physiotherapy | ·· | By consensus, no proven value in acute setting; may be useful in select patients2, 3, 6, 37 | |
| Impaired gas exchange and acute ventilatory failure | Supplemental oxygen (titrated) | +++ | By consensus; decreases pulmonary vasoconstriction and improves end-organ function2, 3 |
| Treat comorbid disorders that impair gas exchange | +++ | By consensus eg, pneumonia, congestive heart failure, pulmonary embolism, pneumothorax2, 3 | |
| Treat comorbid disorders that impair muscle function | +++ | By consensus eg, splinting from rib pain or vertebral fracture, oversedation, malnutrition2, 3 | |
| Doxapram | + | By consensus6 possibly useful in selected patients42† | |
| Non-invasive assisted ventilation | +++ | Risk of intubation decreased in carefully selected patients34, 35† (further reading) | |
| Intubation and mechanical ventilation (when indicated) | +++ | By consensus monitor to keep dynamic hyperinflation and auto-PEEP to minimum2, 3, 6 | |
MDI=metered dose inhaler; PEEP=positive end expiratory pressure. ··=not recommended; +=weak recommendation; ++=moderate recommendation; +++=strong recommendation; R=randomised; DB=double-blind; PC=placebo-controlled.
*
Gradation based on perceived strength of best evidence or by expert consensus.
†
Specific for patients in hospital.