Lesson 1,
Topic 1
In Progress
Pharmacological Management
Bronchodilators
- Short-acting beta2-agonists (albuterol, levalbuterol) – Inhaled beta2-agonists provide rapid bronchodilation and symptom relief. Administered 2-4 puffs every 20 minutes as needed in mild exacerbations, or continuously in severe exacerbations. Can be delivered via MDI or nebulization. Side effects include tremor, tachycardia, hypokalemia.
- Short-acting anticholinergics (ipratropium) – Inhaled anticholinergics also provide bronchodilation but have a slower onset than beta2-agonists. Ipratropium 2-4 puffs every 20 minutes as needed is commonly added to albuterol. Main side effects are dry mouth and urinary retention.
- IV methylxanthines (aminophylline, theophylline) – Not routinely used due to side effects and narrow therapeutic index. Reserved for patients not responding to other bronchodilators. Monitor serum levels.
Corticosteroids
- Oral corticosteroids – Systemic corticosteroids accelerate recovery and improve outcomes in moderate-to-severe exacerbations. Prednisone 30-40 mg PO daily for 5 days is commonly used. Tapering is unnecessary. Side effects include hyperglycemia, insomnia, infection risk.
- Inhaled corticosteroids – High-dose ICS (eg budesonide 1500-2000 mcg/day) may be equivalently effective to oral corticosteroids for initial treatment of exacerbations and causes fewer side effects.
Antibiotics
- Indicated for exacerbations with increased dyspnea, sputum volume, and purulence. Routine use remains controversial.
- First-line options include macrolides (azithromycin), tetracyclines (doxycycline), and 2nd generation cephalosporins. Fluoroquinolones and amoxicillin-clavulanate are alternatives.
- Typical duration 5-7 days. Choice guided by local resistance patterns and patient factors.
Individualized Management
- Mild exacerbations may be managed with temporary increase in short-acting bronchodilators.
- Moderate exacerbations warrant additional treatment with systemic corticosteroids and possibly antibiotics.
- Severe exacerbations require hospitalization for oxygen, corticosteroids, antibiotics, and consideration of ventilatory support.
Clinical judgment based on illness severity, patient characteristics, and response guides treatment. Monitoring for resolution of symptoms, gas exchange normalization, and medication adverse effects is essential.