Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the Elderly : an Appraisal of Published Evidence

Chronic obstructive pulmonary disease (COPD) is a debilitating disease with rising worldwide prevalence. Exacerbations of COPD cause significant morbidity and become more common with advancing age. Healthcare providers caring for elderly patients should therefore be familiar with effective treatments for exacerbations of COPD. An extensive body of literature has identified several effective drug therapies for exacerbations. These drugs include inhaled bronchodilators, systemic corticosteroids and antibacterials. The two main classes of inhaled bronchodilators are beta-adrenoceptor agonists and anticholinergics. These drugs optimise lung function during exacerbations, with neither class demonstrating clear superiority over the other. Systemic corticosteroids are effective when used either for inpatient or outpatient treatment of exacerbations. They hasten recovery from exacerbations and reduce relapse rates. Antibacterials decrease morbidity from exacerbations and may decrease mortality in the more severe exacerbations. Other effective therapies for the treatment of acute exacerbations of COPD include oxygen and non-invasive ventilation. Oxygen can be safely administered in acute exacerbations associated with hypoxaemia, with titration of oxygen delivery to a goal oxygen saturation of 90%. Non-invasive ventilation reduces the morbidity and mortality associated with acute exacerbations complicated by hypercapnic respiratory failure. Strategies to prevent COPD exacerbations include smoking cessation, long-acting inhaled beta-adrenoceptor agonists, inhaled long-acting anticholinergics, inhaled corticosteroids and vaccination. Mucolytic agents, pulmonary rehabilitation, and case management programmes may also reduce exacerbation risk, but the current evidence supporting these interventions is weaker.