X2.2 Optimise treatment

An exacerbation of COPD may involve an increase in airflow limitation, excess sputum production, airway inflam­mation, infection, hypoxia, hypercarbia and acidosis. Treat­ment is directed at each of these problems.

  • Bronchodilators: Inhaled beta-agonist (eg, salbutamol, 400–800mcg; terbutaline, 500–100mcg) and antimuscarinic agent (ipratropium, 80mcg) can be given by pressurised metered dose inhaler and spacer, or by jet nebulisation (salbutamol, 2.5–5 mg; terbutaline, 5 mg; ipratropium, 500mcg). The dose interval is titrated to the response and can range from hourly to six-hourly. There is a lack of evidence in favour of one mode of delivery over another for bronchodilators during exacerbations of COPD. In a Cochrane Review by van Geffen (van Geffen 2016) there were no differences between nebulisers and pressured metered dose inhalers plus spacer regarding the primary outcomes of FEV1 at one hour (MD 36ml, 95% CI −38 to 110, n=40) and serious adverse events (OR 1.00 95% 0.18 to 5.53; n=70) [evidence level I].
  • Corticosteroids: Oral corticosteroids hasten resolution and reduce the likelihood of relapse. Up to two weeks’ therapy with prednisolone (40–50 mg daily) is adequate. Longer courses add no further benefit and have a higher risk of side effects.
  • Antibiotics: Antibiotics are given for purulent sputum to cover for typical and atypical organisms.
  • Controlled oxygen therapy: This is indicated in patients with hypoxia, with the aim of improving oxygen saturation to 88-92%. Use nasal prongs at 0.5–2.0 L/minute or a Venturi mask at 24% or 28%. Minimise excessive oxygen administration, which can worsen hypercapnia.
  • Ventilatory assistance: This is indicated for increasing hypercapnia and acidosis. Non-invasive ventilation by means of a mask is the preferred method.

Although the adherence to pharmacological, rehabilitation and vaccination management as recommended in GOLD have each been shown to reduce health care costs, uptake of GOLD recommendations has had little evaluation. A study in a Victorian hospital setting demonstrated significant overuse of antibiotics and oxygen therapy, as well as a greater evidence practice gap in general medical units than respiratory medical units (Tang 2014) [evidence level III-2].