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8/17/2025 • 12–18 min read

COPD Exacerbation: Steroids, Antibiotics & Ventilation

Acute COPD exacerbation is a gas-exchange problem with airway inflammation and infection on a chronic mechanical disadvantage. This pathway focuses on safe oxygen targets, bronchodilators, short steroid bursts, antibiotic triggers, and when to use noninvasive ventilation (NIV).

Recognize & Differentiate

  • Symptoms: increased dyspnea, cough, sputum volume/purulence, chest tightness, wheeze, fatigue.
  • Consider mimics/overlaps: pneumonia, heart failure, pulmonary embolism, pneumothorax, asthma, COVID-19/influenza, aspiration.
  • Initial tests: vitals, pulse oximetry (and ABG/VBG if moderate–severe), chest X-ray, ECG; viral testing seasonally; basic labs.

Oxygen & Ventilation Targets

  • Target SpO₂ 88–92% to reduce CO₂ retention/worsening hypercapnia. Use nasal cannula or Venturi mask.
  • NIV (BiPAP) indications: moderate–severe dyspnea with accessory muscle use; respiratory acidosis (pH ≤7.35 with hypercapnia); persistent hypoxemia despite supplemental O₂.
  • Intubate for refractory hypoxemia, inability to protect airway, severe agitation/encephalopathy, or hemodynamic collapse.

Bronchodilators (first line)

  • SABA (albuterol/salbutamol) via MDI + spacer or nebulizer, repeated q20 min initially.
  • SAMA (ipratropium) added early provides additional bronchodilation.
  • Continue patient’s home LABA/LAMA once stable; theophylline is not recommended for acute use.

Steroids

  • Prednisone 40 mg PO daily × 5 days (or equivalent). IV methylprednisolone if unable to take PO.
  • Longer courses rarely needed; taper is usually unnecessary for ≤2 weeks in non-steroid-dependent patients.

Antibiotics — Who Needs Them?

Start when any of the following are present:

  • Increased sputum purulence with either ↑sputum volume or ↑dyspnea,
  • Need for ventilatory support (NIV or intubation),
  • Clinical/radiographic pneumonia (treat per CAP pathway).

Choices (tailor to local resistance/allergy):

  • Mild–moderate: amoxicillin-clavulanate, doxycycline, or azithromycin.
  • Severe/frequent exacerbations or Pseudomonas risk (prior isolation, bronchiectasis, recent broad-spectrum antibiotics):levofloxacin or antipseudomonal beta-lactam per protocol.
  • Duration: typically 5–7 days (longer for severe cases or if Pseudomonas).

Adjuncts

  • Controlled fluids if dehydrated; avoid volume overload.
  • Chest physiotherapy/airway clearance where secretions are tenacious.
  • Venous thromboembolism prophylaxis during admission unless contraindicated.

ABG/VBG & Acid–Base

  • Expect chronic compensated hypercapnia in advanced COPD; interpret pH to judge acute decompensation.
  • Rising PaCO₂ with falling pH despite therapy → escalate (NIV or intubation).

When to Admit vs Discharge

  • Admit for severe dyspnea, new/worsening hypoxemia, respiratory acidosis, signs of respiratory muscle fatigue, pneumonia, high-risk comorbidity, or social barriers.
  • Discharge when stable on room air or home O₂ baseline, ambulating, eating, with clear inhaler plan and follow-up within 1–2 weeks.

Relapse Prevention & Long-Term Optimization

  • Inhaled regimen: ensure correct technique; escalate to LAMA or LAMA/LABA; consider ICS add-on (triple therapy) in frequent exacerbators, especially with higher blood eosinophils.
  • Smoking cessation (behavioral + pharmacotherapy), vaccinations (influenza, pneumococcal, COVID-19), and pulmonary rehabilitation.
  • Roflumilast for chronic bronchitis phenotype with frequent exacerbations and low FEV₁; watch GI/weight effects.
  • Home O₂ for severe resting hypoxemia per criteria; consider home NIV in chronic hypercapnic failure after careful selection.

Red Flags & Pearls

  • Sudden pleuritic pain or asymmetric breath sounds → evaluate for pneumothorax or PE.
  • Aim for SpO₂ 88–92%; avoid routine high-flow O₂ without indication.
  • Azithromycin QT risk; review meds and electrolytes. Fluoroquinolones carry tendinopathy and QT risks—reserve appropriately.

Patient FAQs

“Why not give me lots of oxygen?” Too much O₂ can worsen CO₂ retention in COPD—targeted oxygen keeps you safe while we treat the flare.

“Do I need antibiotics every time?” Not always; we use them when sputum becomes purulent or you need ventilatory support.

References & Notes

Practical COPD pathway: titrated oxygen (88–92%), SABA/SAMA, short steroid course (prednisone 40 mg ×5), antibiotic triggers based on Anthonisen criteria/ventilatory support, and NIV for hypercapnic acidosis. Local protocols vary—follow institutional guidance. Educational only.

Educational only, not personal medical advice.