pulmonary disorders
Treatment of Acute COPD Exacerbation
Drug Therapy in Acute COPD Exacerbation
Beta-agonists and anticholinergics, with or without corticosteroids, should be started concurrently with oxygen therapy (regardless of how oxygen is administered) with the aim of reversing airway obstruction. Methylxanthines, once considered essential to treatment of acute COPD exacerbations, are no longer used; toxicities exceed benefits. Short-acting beta-agonists are the cornerstone of drug therapy for acute exacerbations. The most widely used drug isalbuterol2.5 mg by nebulizer or 2 to 4 puffs (100 mcg/puff) by metered-dose inhaler every 2 to 6 hours. Inhalation using a metered-dose inhaler causes rapid bronchodilation; there are no data indicating that doses taken with nebulizers are more effective than the same doses correctly taken with metered-dose inhalers. In cases of severe, unresponsive bronchospasm, continuous nebulizer treatments may sometimes be administered. Ipratropium, an anticholinergic, is effective in acute COPD exacerbations and should be given concurrently or alternating with beta-agonists. Dosage is 0.25 to 0.5 mg by nebulizer or 2 to 4 inhalations (17 to 18 mcg of drug delivered per puff) by metered-dose inhaler every 4 to 6 hours.Ipratropiumgenerally provides bronchodilating effect similar to that of usual recommended doses of beta-agonists. The role of the longer-acting anticholinergic drugs in treating acute exacerbations has not been defined. Corticosteroids should be begun immediately for all but mild exacerbations. Options includeprednisone30 to 60 mg orally once a day for 5 to 7 days and stopped directly or tapered over 7 to 14 days depending on the clinical response. A parenteral alternative ismethylprednisolone60 to 500 mg IV once a day for 3 days and then tapered over 7 to 14 days. These drugs are equivalent in their acute effects. Antibiotics are recommended for exacerbations in patients with purulent sputum. Some physicians give antibiotics empirically for change in sputum color or for nonspecific chest x-ray abnormalities. Routine cultures and Gram stains are not necessary before treatment unless an unusual or resistant organism is suspected (eg, in hospitalized, institutionalized, or immunosuppressed patients). Drugs directed against oral flora are indicated. Examples of antibiotics that are effective are Trimethoprim/sulfamethoxazole 160 mg/800 mg orally twice a day Amoxicillin250 to 500 mg orally 3 times a day Doxycycline50 to 100 mg orally twice a day Azithromycin500 mg orally once a day Choice of drug is dictated by local patterns of bacterial sensitivity and patient history.Trimethoprim/sulfamethoxazole,amoxicillin, anddoxycyclineare give for 7 to 14 days. An alternative first-line antibiotic isazithromycin500 mg orally once a day for 3 days or 500 mg orally as a single dose on day 1, followed by 250 mg once a day on days 2 through 5. When patients are seriously ill or clinical evidence suggests that the infectious organisms are resistant, broader spectrum 2nd-line drugs can be used. These drugs includeamoxicillin/clavulanate, fluoroquinolones (eg,ciprofloxacin,levofloxacin), and 2nd-generation cephalosporins (eg,cefuroxime,cefaclor). These drugs are effective against beta-lactamase–producing strains ofHaemophilus influenzaeandMoraxella catarrhalisbut have not been shown to be more effective than first-line drugs for most patients. Patients can be taught to recognize a change in sputum from normal to purulent as a sign of impending exacerbation and to start a 10- to 14-day course of antibiotic therapy. Long-term antibiotic prophylaxis is recommended only for patients with underlying structural changes in the lung, such as bronchiectasis or infected bullae. In patients with frequent exacerbations, long-term macrolide use reduces exacerbation frequency but may have adverse effects. Antitussives,such asdextromethorphanandbenzonatate, have little role. Opioids(eg,codeine,hydrocodone,oxycodone) should be used judiciously for relief of symptoms (eg, severe coughing paroxysms, pain) insofar as these drugs may suppress a productive cough, impair mental status, and cause constipation. 