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Adapted from COPD-X Guidelines; April 2009 revision
- Early diagnosis and treatment may prevent hospital admission
- Inhaled bronchodilators are effective for the treatment of acute exacerbations
- Oral prednisone reduces the severity and shortens recovery time from acute exacerbations
- Antibiotics may be beneficial if there are clinical signs of infection
Exacerbation is a change from baseline
An acute exacerbation of COPD is characterised by a change in a person’s baseline dyspnoea, cough and/or sputum production
that is greater than day to day variation (definition from the Global Initiative for Obstructive Lung Disease – GOLD).
Lung inflammation and infection appear to play an important role in the pathogenesis of worsening symptoms. The most
common triggers are viral or bacterial infections. Non-infectious causes include left ventricular failure, pulmonary embolus,
environmental irritants, chest trauma and inappropriate sedative use.
Early diagnosis and prompt management may prevent progression and admission
Assessment of the severity of the exacerbation includes measurement of blood pressure, respiratory rate and oxygen saturation
(if pulse oximetry is available). The need for hospital admission is based on clinical findings and social circumstances.
Educating the patient and their carers about the signs of worsening COPD may be helpful in early detection of an exacerbation.
A self-management plan which describes how to step up treatment is also beneficial. The plan should include advice on
bronchodilator use, when to start oral prednisone, and the indications for antibiotic use.
Optimise the dose of bronchodilator
During exacerbations of COPD the immediate effect of a bronchodilator is small, but for those with severe obstruction,
there may be a significant improvement in clinical symptoms. Bronchodilators may reduce air trapping.
A short acting beta-2 agonist (salbutamol 400 – 800 mcg) or ipratropium 80 mcg can be given by pressurised metered dose
inhaler (MDI) and spacer. The dose interval is titrated to response and can range from hourly to six-hourly.
If the patient is using a long acting beta-2 agonist (LABA) or tiotropium, they should be continued during the treatment
of the exacerbation.
Glucocorticoids are beneficial
Oral prednisone can speed up the resolution of exacerbations and also reduce the risk of relapse. There is little evidence
that IV steroids are better than oral. The optimal oral dose has not been established. Prednisone 40 mg taken as a single
daily dose in the morning, for up to two weeks, is sufficient in most cases. It is traditional to do a tapering dose,
but this is not necessary after such a short course. Longer courses add no further benefit and have a greater risk of
If the patient is already using an inhaled corticosteroid (ICS), this can be continued while taking a short course of
prednisone, but it is useful to check the inhaler technique as the main benefit of ICS is reducing the frequency of exacerbations
in those with severe COPD. Patients who are taking long-term, low-dose prednisone should not be using ICS at the same
Antibiotics have specific indications
Viral infections are a significant cause of exacerbations. Bacterial infections (predominantly Haemophilus influenzae,
Streptococcus pneumoniae, Moraxella catarrhalis
) have a primary or secondary role in about 50% of acute exacerbations
of COPD. Sputum culture is not routinely required, but may be helpful if there is no improvement with treatment.
The benefits of antibiotic use are unclear. They are only recommended if there are at least two new findings of: increased
purulent sputum, increased sputum production or increased dyspnoea.
First-line: Amoxicillin 500 mg three times a day for five days
Alternative: Doxycycline 100 mg twice daily for five days (if penicillin allergic or recent course of amoxicillin).
Amoxicillin clavulanate is only indicated if there has been clinical failure with first-line antibiotics.
Ciprofloxacin does not have adequate coverage against S. pneumoniae and should not be used for the management
of acute exacerbations of COPD.
When to refer
Mortality rates from exacerbations of COPD increase with acute carbon dioxide retention (respiratory acidosis), the
presence of co-morbidities (e.g. heart failure and IHD) and complications such as pneumonia. Depending on the circumstances
and severity of the exacerbation urgent hospital admission may be required for ventilatory support and other intensive
Indications for referral to secondary care;
- Inability to walk short distances when previously mobile
- Inability to eat or sleep because of dyspnoea
- Inability to manage at home even with help
- High risk co-morbid condition
- Altered mental state suggestive of hypercapnia
- Worsening cor pulmonale or hypoxaemia
- New appearance of arrhythmia
- Inadequate response to management in primary care
- Uncertainty of diagnosis
Strategies to reduce the frequency of exacerbations
Exacerbations of COPD, especially if severe, are associated with increased mortality. Strategies to reduce the frequency
of exacerbations should be considered and be part of an individual management plan. Strategies include:
- Influenza vaccination (yearly) and pneumococcal vaccination (five yearly)
- Minimising infection risk, such as avoiding contact with people with an active URTI
- Avoiding exposure to smoke and irritants
- Optimising control of co-morbidities
- Use of medication
Inhaled corticosteroids (including when combined with LABA) reduce the rate of exacerbations however they do not improve
mortality and their effect on the decline in lung function remains unclear. They should be considered for patients with
severe COPD and frequent exacerbations (e.g. two or more exacerbations in a year requiring treatment with an antibiotic
or oral corticosteroid). Systemic absorption may occur, especially when high doses are used, therefore the benefit of
ICS must be weighed against the risk of adverse effects, such as bruising, cataracts and osteoporosis.
Tiotropium decreases exacerbations as well as improving lung function, symptoms and quality of life. The number needed
to treat (NNT) for one year to prevent one exacerbation is 14 and the NNT is 30 to prevent one hospitalization. Adverse
effects of tiotropium include dry mouth and infrequently, urinary retention.
COPD-X Guidelines April 2009 revision.Available from: www.copdx.org.au/the-copd-guidelines
GOLD - Global initiative for obstructive lung disease. Available from: www.goldcopd.com
Quon B, Gan W, Sin D. Contemporary management of acute exacerbations of COPD. A systematic review and meta-analysis.
Puhan MA, Bachmann L, Kleijnen J, et al. Inhaled drugs to reduce exacerbations in patients with chronic obstructive
pulmonary disease; a network meta-analysis. BMC Medicine 2009;7:2. Available from: www.biomedcentral.com/1741-7015/7/2