Skip to main content
SpringerLink
Log in

Pharmacological Treatment in Acute Exacerbations of Chronic Obstructive Pulmonary Disease

  • Review Article
  • Disease Management
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Summary

Exacerbations of chronic obstructive pulmonary disease (COPD) are usually treated with bronchodilator therapy, glucocorticoids and antibiotics. However, there are few experimental data on the effects of these agents in patients with acute COPD. A β2-adrenoceptor agonist is usually given first because it can be expected to produce a rapid response. An anticholinergic agent should also be given when the patient is severely ill or responds inadequately to the β2 agonist. These agents can be administered via a nebuliser or using a metered-dose inhaler in conjunction with a spacer device. Glucocorticoids can accelerate recovery if the standard empirical regimens for acute exacerbations of asthma are used, although a longer treatment duration appears to be required. Theophylline provides little additional benefit in patients who receive frequent doses of inhaled bronchodilators and an adequate dosage of a glucocorticoid. Although the role of bacterial infections is not completely understood, the use of antibiotics is justified in patients with severe airflow limitation who have febrile tracheobronchitis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995; 152 (5 Pt 2): S77–121

    Google Scholar 

  2. Siafakas NM, Vermeire P, Pride NB, et al. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). The European Respiratory Society Task Force. Eur Respir J 1995; 8: 1398–420

    Article  PubMed  CAS  Google Scholar 

  3. Curtis JR, Hudson LD. Emergent assessment and management of acute respiratory failure in COPD. Clin Chest Med 1994; 15: 418–500

    Google Scholar 

  4. Stefano ADI, Turato G, Maestrelli P, et al. Airflow limitation in chronic bronchitis is associated with T-lymphocyte and macrophage infiltration of the bronchial mucosa. Am J Respir Crit Care Med 1996; 153: 629–32

    PubMed  Google Scholar 

  5. Saetta M, Stefano ADI, Maestrelli P, et al. Airway eosinophilia and expression of interleukin-5 protein in asthma and in exacerbations of chronic bronchitis. Clin Exp Allergy 1996; 26: 766–74

    Article  PubMed  CAS  Google Scholar 

  6. Hagedorn SD. Acute exacerbations of COPD. Postgrad Med 1992; 91: 105–7, 110-2

    PubMed  CAS  Google Scholar 

  7. Dulfano MJ, Glass P. The bronchodilator effects of terbutaline: route of administration and patterns of response. Ann Allergy 1976; 37: 357–66

    PubMed  CAS  Google Scholar 

  8. van Schayck CP, Folgering H, Harbers H, et al. Effects of allergy and age on responses to salbutamol and ipratropium bromide in moderate asthma and chronic bronchitis. Thorax 1991; 46: 355–9

    Article  PubMed  Google Scholar 

  9. Lipworth BJ, Clark RA, Dhillon DP, et al. Comparison of β-adrenoceptor responsiveness following prolonged treatment with low and high doses of inhaled terbutaline in chronic obstructive pulmonary disease. Am Rev Respir Dis 1990; 142: 338–42

    PubMed  CAS  Google Scholar 

  10. Turner JR, Corkery KJ, Eckman D, et al. Equivalence of continuous flow nebulizer and metered-dose inhaler with reservoir bag for treatment of acute airflow obstruction. Chest 1988; 93: 476–81

    Article  PubMed  CAS  Google Scholar 

  11. Fuller HD, Dolovich MB, Posmituck G, et al. Pressurized aerosol versus jet aerosol delivery to mechanically ventilated patients: comparison of dose to the lungs. Am Rev Respir Dis 1990; 141: 164–8

    Google Scholar 

  12. Gross N, Bankwala Z. Effects of anticholinergic bronchodilator on arterial blood gases of hypoxemic patients with chronic obstructive pulmonary disease: comparison with a beta-adrenergic agent. Am Rev Respir Dis 1987; 136: 1091–4

    Article  PubMed  CAS  Google Scholar 

  13. Conradson TB, Eklund G, Olofsson B, et al. Arrhythmogenicity from combined bronchodilator therapy in patients with obstructive lung disease and concomitant ischemic heart disease. Chest 1987; 91: 5–9

    Article  PubMed  CAS  Google Scholar 

  14. Sly RM, Jenne JW, Cohn J. Toxicity of beta-adrenergic drugs. In: Jenne JW, Murphy S, editors. Lung biology in health and disease. Vol. 31. Drug therapy for asthma: research and clinical practice. New York: Marcel Dekker, 1987: 953–96

    Google Scholar 

  15. Boulet LP. Long- versus short-acting β2-agonists: implications for drug therapy. Drugs 1994; 47: 207–22

    Article  PubMed  CAS  Google Scholar 

  16. Siefkin AD. Optimal pharmacologic treatment of the critically ill patient with obstructive airways disease. Am J Med 1996; 100Suppl. 1A: 54S–61S

    Article  PubMed  CAS  Google Scholar 

  17. Hughs JA, Tobin MJ, Bellamy D, et al. Effects of ipratropium bromide and fenoterol aerosols in pulmonary emphysema. Thorax 1982; 37: 667–70

    Article  Google Scholar 

  18. Easton PA, Jadue C, Dhingra S, et al. A comparison of the bronchodilating effects of a beta-2 adrenergic agent (albuterol) and an anticholinergic agent (ipratropium bromide), given by aerosol alone or in sequence. N Engl J Med 1986; 315: 735–9

    Article  PubMed  CAS  Google Scholar 

  19. Poppius H, Salorinne Y. Comparative trial of a new anticholinergic bronchodilator, Sch 1000, and salbutamol in chronic bronchitis. BMJ 1973; 4: 134–6

    Article  PubMed  CAS  Google Scholar 

  20. Tashkin DP, Ashutosh K, Bleecker ER, et al. Comparison of the anticholinergic bronchodilator ipratropium bromide with metaproterenol in chronic obstructive pulmonary disease: a 90-day multi-center study. Am J Med 1986; 81Suppl. 5A: 59–67

    Google Scholar 

  21. Braun SR, McKenzie WN, Copeland C, et al. A comparison of the effect of ipratropium and albuterol in the treatment of chronic obstructive airways disease. Arch Intern Med 1989; 149: 544–7

    Article  PubMed  CAS  Google Scholar 

  22. Koyama H, Nishimura K, Ikeda A, et al. A comparison of the bronchodilating effects of oxitropium bromide and fenoterol in patients with chronic obstructive pulmonary disease. Chest 1993; 104: 1743–7

    Article  PubMed  CAS  Google Scholar 

  23. Karpel JP. Bronchodilator response to anticholinergic agents in acute and stable COPD. Chest 1991; 99: 871–6

    Article  PubMed  CAS  Google Scholar 

  24. Gross NJ, Petty TL, Friedman M, et al. Dose response to ipratropium bromide as a nebulized solution in patients with chronic obstructive pulmonary disease: a three center study. Am Rev Respir Dis 1989; 139: 1188–91

    PubMed  CAS  Google Scholar 

  25. Hockley B, Johnson NM. A comparison of three high dosages of ipratropium bromide in chronic asthma. Br J Dis Chest 1985; 79: 379–84

    Article  PubMed  CAS  Google Scholar 

  26. Ikeda A, Nishimura K, Koyama H, et al. Comparative dose-response study of three anticholinergic agents and fenoterol using a metered dose inhaler in patients with chronic obstructive pulmonary disease. Thorax 1995; 50: 62–6

    Article  PubMed  CAS  Google Scholar 

  27. Lightbody IM, Ingram CG, Legge JS, et al. Ipratropium bromide, salbutamol and prednisolone in bronchial asthma and chronic bronchitis. Br J Dis Chest 1978; 72: 181–6

    Article  PubMed  CAS  Google Scholar 

  28. Douglas NJ, Davidson I, Sudlow MF, et al. Bronchodilatation and the site of airway resistance in severe chronic bronchitis. Thorax 1979; 34: 51–6

    Article  PubMed  CAS  Google Scholar 

  29. Ikeda A, Nishimura K, Koyama H, et al. Bronchodilating effects of combined therapy with clinical dosages of ipratropium bromide and salbutamol for stable COPD: comparison with ipratropium bromide alone. Chest 1995; 107: 401–5

    Article  PubMed  CAS  Google Scholar 

  30. LeDoux EJ, Morris JF, Temple WP, et al. Standard and double dose ipratropium bromide and inhaled metaproterenol in COPD. Chest 1989; 95: 1013–6

    Article  PubMed  CAS  Google Scholar 

  31. Karpel JP, Pesin J, Greenberg G, et al. A comparison of ipratropium bromide and metaproterenol sulfate in acute exacerbations of COPD. Chest 1990; 98: 835–9

    Article  PubMed  CAS  Google Scholar 

  32. Moayyedi P, Congleton J, Page RL, et al. Comparison of nebulised salbutamol and ipratropium bromide with salbutamol alone in the treatment of chronic obstructive pulmonary disease. Thorax 1995; 50: 834–7

    Article  PubMed  CAS  Google Scholar 

  33. Filuk RB, Easton PA, Anthonisen NR. Responses to large doses of salbutamol and theophylline in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1985; 132: 871–4

    PubMed  CAS  Google Scholar 

  34. Lam A, Newhouse MT. Management of asthma and chronic airflow limitation: are methylxanthines obsolete? Chest 1990; 98: 44–52

    Article  PubMed  CAS  Google Scholar 

  35. Bleeker ER, Britt EJ. Acute bronchodilating effects of ipratropium bromide and theophylline in chronic obstructive pulmonary disease. Am J Med 1991; 91Suppl. 4A: 24S–7S

    Article  Google Scholar 

  36. Nishimura K, Koyama H, Ikeda A, et al. The additive effect of theophylline on a high-dose combination of inhaled salbutamol and ipratropium bromide in stable COPD. Chest 1995; 107: 718–23

    Article  PubMed  CAS  Google Scholar 

  37. Sullivan P, Bekir S, Jaffar Z, et al. Anti-inflammatory effects of low-dose oral theophylline in atopic asthma. Lancet 1994; 343: 1006–8

    Article  PubMed  CAS  Google Scholar 

  38. Kidney JH, Dominguez M, Taylor PM, et al. Immunomodulation by theophylline in asthma. Am J Respir Crit Care Med 1995; 151: 1907–14

    PubMed  CAS  Google Scholar 

  39. Rice KL, Leatherman JW, Duane PG, et al. Aminophylline for acute exacerbations of chronic obstructive pulmonary disease: a controlled trial. Ann Intern Med 1987; 107: 305–9

    PubMed  CAS  Google Scholar 

  40. Morris HG. Mechanisms of glucocorticoid action in pulmonary disease. Chest 1985; 88 (2 Suppl.): 133S–41S

    Article  PubMed  CAS  Google Scholar 

  41. Callahan CM, Dittus RS, Katz BP. Oral corticosteroid therapy for patients with stable chronic obstructive pulmonary disease: a meta-analysis. Ann Intern Med 1991; 114: 216–23

    PubMed  CAS  Google Scholar 

  42. Weir DC, Gove RI, Robertson AS, et al. Corticosteroid trials in non-asthmatic chronic airflow obstruction: a comparison of oral prednisolone and inhaled beclomethasone dipropionate. Thorax 1990; 45: 112–7

    Article  PubMed  CAS  Google Scholar 

  43. Emerman CL, Connors AF, Lukens ME, et al. A randomized controlled trial of methylprednisolone in the emergency treatment of acute exacerbations of COPD. Chest 1989; 95: 563–7

    Article  PubMed  CAS  Google Scholar 

  44. Albert RK, Martin TR, Lewis SW. Controlled clinical trial of methylprednisolone in patients with chronic bronchitis and acute respiratory insufficiency. Ann Intern Med 1980; 92: 753–8

    PubMed  CAS  Google Scholar 

  45. Thompson WH, Nielson CP, Carvalho P, et al. Controlled trial of oral prednisolone in outpatients with acute COPD exacerbation. Am J Crit Care Med 1996; 154: 407–12

    CAS  Google Scholar 

  46. Derenne JP, Fleury B, Pariente R. Acute respiratory failure and chronic obstructive pulmonary disease. Am Rev Respir Dis 1988; 138: 1006–33

    Article  PubMed  CAS  Google Scholar 

  47. Murphy TF, Sethi S. Bacterial infection in chronic obstructive pulmonary disease. Am Rev Respir Dis 1992; 146: 1067–83

    PubMed  CAS  Google Scholar 

  48. Monso E, Ruiz J, Rosell A, et al. Bacterial infection in chronic obstructive pulmonary disease: a study of stable and exacerbated outpatients using the protected specimen brush. Am J Respir Crit Care Med 1995; 152: 1316–20

    PubMed  CAS  Google Scholar 

  49. Fagon JY, Chastre J. Severe exacerbations of COPD patients: the role of pulmonary infections. Semin Respir Infect 1996; 11: 109–18

    PubMed  CAS  Google Scholar 

  50. Blasi F, Legnani D, Lombardo VM, et al. Chlamydia pneumoniae infection in acute exacerbations of COPD. Eur Respir J 1993; 6: 19–22

    PubMed  CAS  Google Scholar 

  51. Anthonisen NR, Manfreda J, Warren CPW, et al. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 1987; 106: 196–204

    PubMed  CAS  Google Scholar 

  52. Nicotra MB, Rivera M, Awe RJ. Antibiotic therapy of acute exacerbations of chronic bronchitis: a controlled study using tetracycline. Ann Intern Med 1982; 97: 18–21

    PubMed  CAS  Google Scholar 

  53. Sachs APE, Koëter GH, Groenier KH, et al. Changes in symptoms, peak expiratory flow, and sputum flora during treatment with antibiotics of exacerbations in patients with chronic obstructive pulmonary disease in general practice. Thorax 1995; 50: 758–63

    Article  PubMed  CAS  Google Scholar 

  54. Saint S, Bent S, Vittinghoff E, et al. Antibiotics in chronic obstructive pulmonary disease exacerbations: a meta-analysis. JAMA 1995; 273: 957–60

    Article  PubMed  CAS  Google Scholar 

  55. Sergysels R. Chest physiotherapy from chronic to acute respiratory failure in chronic obstructive lung disease. In: Derenne JP, Whitelaw WA, Similowski T, editors. Acute respiratory failure in chronic obstructive pulmonary disease. New York: Marcel Dekker, 1996: 615–34

    Google Scholar 

  56. Petty TL. The National Mucolytic Study: results of a randomized, double-blind, placebo-controlled study of iodinated glycerol in chronic obstructive bronchitis. Chest 1990; 97: 75–83

    Article  PubMed  CAS  Google Scholar 

  57. Rubin BK, Ramirez O, Ohar JA. Iodinated glycerol has no effect on pulmonary function, symptom score, or sputum properties in patients with stable chronic bronchitis. Chest 1996; 109: 348–52

    Article  PubMed  CAS  Google Scholar 

  58. Rasmussen JB, Glennow C. Reduction in days of illness after long-term treatment with N-acetylcysteine controlled-release tablets in patients with chronic bronchitis. Eur Respir J 1988; 1: 351–5

    PubMed  CAS  Google Scholar 

  59. Hansen NC, Skriver A, Brorsen RL, et al. Orally administered N-acetylcysteine may improve general well-being in patients with mild chronic bronchitis. Respir Med 1994; 88: 531–5

    Article  PubMed  CAS  Google Scholar 

  60. Bridgeman MM, Marsden M, Selby C, et al. Effect of N-acetyl cysteine on the concentrations of thiols in plasma, bronchoalveolar lavage fluid, and lung tissue. Thorax 1994; 49: 670–5

    Article  PubMed  CAS  Google Scholar 

  61. Vilkman S, Keistinen T, Tuuponen T, et al. Age distribution of patients in hospital for chronic obstructive pulmonary disease. Age Ageing 1995; 25: 109–12

    Article  Google Scholar 

  62. Chang JT, Moran MB, Cugell DW, et al. COPD in the elderly: a reversible cause of functional impairment. Chest 1995; 108: 736–40

    Article  PubMed  CAS  Google Scholar 

  63. Teramoto S, Fukuchi Y. Improvements in exercise capacity and dyspnoea by inhaled anticholinergic drug in elderly patients with chronic obstructive pulmonary disease. Age Ageing 1995; 24: 278–82

    Article  PubMed  CAS  Google Scholar 

  64. Couser JI, Guthmann R, Hamadeh MA, et al. Pulmonary rehabilitation improves exercise capacity in elderly patients with COPD. Chest 1995; 107: 730–4

    Article  PubMed  Google Scholar 

  65. Nielsen-Kudsk F, Magnussen T, Jakobsen N. Pharmacokinetics of theophylline in ten elderly patients. Acta Pharmacol Toxicol Copenh 1978; 42: 226–34

    Article  PubMed  CAS  Google Scholar 

  66. Morris JF. Physiological changes due to age: implications for respiratory drug therapy. Drugs Aging 1994; 4: 207–20

    Article  PubMed  CAS  Google Scholar 

  67. Tobin MJ, Jenouri G, Danta I, et al. Response to bronchodilator drug administration by a new reservoir delivery system and a review of other auxiliary delivery systems. Am Rev Respir Med 1982; 126: 670–5

    CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Chest Disease Research Institute, Kyoto University, 53 Shogoin kawara-machi, Sakyo-Ku, Kyoto, 606-01, Japan

    Akihiko Ikeda, Koichi Nishimura & Takateru Izumi

Authors
  1. Akihiko Ikeda
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Koichi Nishimura
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Takateru Izumi
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ikeda, A., Nishimura, K. & Izumi, T. Pharmacological Treatment in Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Drugs & Aging 12, 129–137 (1998). https://doi.org/10.2165/00002512-199812020-00005

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002512-199812020-00005

Keywords

Search

Navigation