Inhaled bronchodilators
An exacerbation of chronic obstructive pulmonary disease (COPD) is managed with bronchodilator therapy at the onset of symptoms. Bronchodilator therapy can be started by the patient at home, in accordance with their written COPD action plan.
Salbutamol, terbutaline and ipratropium appear to work equally well to relieve the symptoms of a COPD exacerbation; however, ipratropium has a slower onset of effect than salbutamol and is contraindicated in patients taking a long-acting muscarinic antagonist (LAMA).
Delivery via pressurised metered dose inhaler (pMDI) with spacer appears to be as effective as delivery via nebuliser for patients with forced expiratory volume in 1 second (FEV1) more than 30% of predicted (although this is based on studies in patients with asthma).
For initial treatment of an exacerbation of COPD, use:
1 salbutamol 100 micrograms per actuation, up to 8 actuations (one at a time) via pMDI with spacer, repeated as required1 chronic obstructive pulmonary disease, exacerbation salbutamol
OR
2 terbutaline 500 micrograms per actuation, 1 or 2 actuations via DPI, repeated as required2 chronic obstructive pulmonary disease, exacerbation terbutaline
OR (except in patients taking a LAMA)
2 ipratropium 21 micrograms per actuation, up to 4 actuations (one at a time) via pMDI with spacer, repeated as required. chronic obstructive pulmonary disease, exacerbation ipratropium
If a nebuliser is required, it should be driven by compressed air rather than oxygen, to avoid excessive and potentially fatal hyperoxygenation. If appropriate, use:
1 salbutamol 2.5 to 5 mg by inhalation via nebuliser, as required salbutamol
OR (except in patients taking a LAMA)
2 ipratropium 250 to 500 micrograms by inhalation via nebuliser, as required. ipratropium
If one drug does not control symptoms adequately, or if symptoms are severe, combining salbutamol and ipratropium (at the above doses) may provide added benefits without compounding adverse effects.
Bronchodilator therapy may be sufficient to relieve a mild COPD exacerbation. The patient does not necessarily need to seek urgent medical attention, but they should report the exacerbation to their doctor at their next appointment.
If symptoms remain uncontrolled, or if repeat doses are required more frequently than 3-hourly, the patient should seek medical attention, and enact the next steps of their written COPD action plan.