The management of acute exacerbations of COPD relies on the recognition of the diagnosis, prompt treatment with bronchodilators and steroids with the correct choice of antimicrobials. Oxygen therapy is also key.

Diagnosis
There are several definitions of an acute exacerbation however the oldest is still probably the best and was developed by Anthonisen in the 1980's. It defines an exacerbation as any 2 of the following in a patient with COPD (i) Shortness of Breath, (ii) Increased sputum production or (iii) Increasing sputum purulence. However this can miss some exacerbating patients who do not produce sputum and those in whom the exacerbation is cause by a virus. Anthonisens definition was further enhanced by the East London COPD group as 2 Consecutive days of: 2 or more of three major symptoms  (i) Shortness of Breath, (ii) Increased sputum production or (iii) Increasing sputum purulence. Or the following minor symptoms, increase in nasal discharge, wheeze, sore throat, cough or fever with one major symptom.

Bronchodilators
During an exacerbation patients need to increase the use of bronchodilator treatment. This is achieved either via MDI or Nebuliser depending on the severity of the disease, and the severity of the exacerbation. Mild and moderate patients, and those suffering with mild or moderate exacerbations may be able to use MDI delivered salbutamol and ipratropium to control their symptoms. The patients with severe and very severe disease, or those suffering with a severe exacerbation will need to receive their bronchodilator therapy via a nebuliser. During an exacerbation the following changes are often made:

• Salbutamol 2 puffs via MDI every 4-6 hours (via spacer) or 2.5mg nebulised 4-6 hourly
• Ipratropium 2 puffs via MDI every 6 hours (via spacer) or 500mcg nebulised 6 hourly
• LABA/ICS combinations to continue as prescribed
• Tiotropium is usually stopped in preference to ipratropium during the exacerbation and then re started after a few days

Prednisolone
All patients with COPD experiencing an acute exacerbation of COPD should receive a short course of steroids. The original paper comparing the use of prednisone vs. placebo revealed that those receiving steroids experienced a much faster improvement in FEV1 and had fewer days in hospital. The dose of prednisolone is 30mg OD for 7 days. 

If there is no improvement then this can be continued at this dose for 14 days but should be stopped at this stage (If the patient has still not improved then another reason should be sought after e.g. resistant organism, pneumonia, heart failure or pulmonary embolus)

Antibiotics
Antibiotic choice is always going to be controversial however the underlying principles are

Choice must be tailored to resistance patterns
Must cover the main pathogens
Oral route is preferred
OD treatment aids compliance

In Southampton there is significant resistance to Amoxicillin and Augmentin and therefore our recommendations are:

Doxycycline 200mg BD for 2 days then 200mg OD for 5 days

Azithromycin 500mg OD 3-5 days

Oxygen Therapy
If the patient is hypoxic then saturations should be maintained initially at 88-92% - especially pre hospital. Thereafter arterial blood gases guide the flow rate.

Care in the community
The table below is a guide to who could be managed in the community and who should be referred into secondary care. This table is adapted from the new NICE guidelines. If in doubt whether the patient may need admission then a referral to the Respiratory Team should be sought.