Exacerbations of
COPD are common and cause a considerable burden to the patient and the healthcare system. To optimize the hospital care of patients with exacerbations of
COPD, clinicians should be aware of some key points: management of exacerbations is broadly based on clinical features and severity. Initial clinical evaluation is crucial to define those patients requiring hospital admission and those who could be managed as outpatients. In hospitalized patients, the appropriate level of care should be determined by the initial severity and response to initial medical treatment. Medical treatment should follow recent recommendations, including rest, titrated
oxygen therapy, inhaled or nebulized short-acting
bronchodilators (Beta2-agonists and
anticholinergic agents), DVT prevention with
LMWH,
steroids in most severely ill patients, unless there are
contraindications and
antibiotics in the case of a clear bacterial infectious aetiology. Severe exacerbations may lead to
acute hypercapnic respiratory failure. Unless contraindicated,
non-invasive ventilation (NIV) should be the first line ventilatory support for these patients. NIV should be commenced early, before severe
acidosis ensues, to avoid the need for endotracheal intubation and to reduce mortality and treatment failures. Several randomised controlled clinical trials support the use of NIV in the management of acute exacerbations of
COPD, demonstrating a decreased need for
mechanical ventilation and an improved survival. In most severe cases, NIV should be provided in ICU. Although it has been shown that for less severe patients (with pH values>7.30), NIV can be administered safely and effectively on general medical wards, a lead respiratory consultant and trained nurses are mandatory.
Mechanical ventilation through an endotracheal tube should be considered when patients have
contraindications to the use of NIV or fail to improve on NIV. The duration of
mechanical ventilation should be shortened as much as possible by an early weaning process, including preventive post-extubation NIV in hypercapnic patients.
hospital stay could be shortened by non-invasive treatments. Future exacerbations should be avoided by respiratory specialist management of the patients, including education, optimization of long-term medical treatment, vaccinations,
nutritional support, and pulmonary rehabilitation.