From the Guidelines
For this 79-year-old male with COPD exacerbation and complicated UTI, I recommend using albuterol (short-acting beta-agonist) 2.5 mg via nebulizer every 4-6 hours, plus ipratropium bromide (anticholinergic) 0.5 mg via nebulizer every 6-8 hours, as the initial bronchodilators to treat the acute exacerbation, as suggested by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1. The patient's symptoms of shortness of breath (SOB) and history of COPD, along with the urinalysis results showing signs of infection, indicate the need for a comprehensive treatment approach.
- The use of albuterol and ipratropium bromide is supported by the evidence, which shows that short-acting inhaled beta-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation 1.
- Additionally, the patient's reduced renal function (eGFR 46) and elevated creatinine (1.53) suggest the need for careful consideration of medication dosing and potential renal toxicity.
- The patient's CBC shows neutrophilia (seg absolute 9.2) indicating infection, and lymphopenia (0.7) suggesting stress response, which further supports the need for antibiotic therapy and close monitoring.
- The patient should be counseled on vaping cessation as it exacerbates his COPD, and oxygen therapy should be provided to maintain saturation between 88-92% due to his COPD status.
- For the complicated UTI, given the patient's reduced renal function, use ceftriaxone 1g IV daily, adjusting based on culture results when available, as suggested by the patient's urinalysis results and clinical presentation. The most recent and highest quality study, the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1, provides the best evidence for the treatment of COPD exacerbations, and its recommendations should be followed in this case.
From the FDA Drug Label
INDICATIONS AND USAGE Ipratropium bromide inhalation solution administered either alone or with other bronchodilators, especially beta adrenergics, is indicated as a bronchodilator for maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease, including chronic bronchitis and emphysema.
The patient has a history of COPD and is experiencing shortness of breath (SOB), which is a symptom of bronchospasm. Given the patient's condition, ipratropium bromide (INH) can be used as a bronchodilator to help manage the patient's COPD exacerbation 2.
From the Research
Treatment for COPD Exacerbation
The patient's symptoms, such as shortness of breath (SOB), can be managed with bronchodilators. According to the study by Anthonisen et al. 3, either a short-acting beta 2-agonist or an anticholinergic is the preferred bronchodilator agent. The choice between the two depends largely on potential undesirable side effects and the patient's coexistent conditions.
Bronchodilator Options
- Short-acting beta 2-agonist: Albuterol is an example of a short-acting beta 2-agonist that can be used to treat COPD exacerbation 4, 5.
- Anticholinergic: Ipratropium is an example of an anticholinergic that can be used to treat COPD exacerbation 4, 5.
- Combination therapy: A combination of ipratropium and albuterol may be more effective than either agent alone in treating COPD exacerbation 5.
Additional Considerations
- Oxygen therapy: Targeted O2 therapy can improve outcomes and should be titrated to an SpO2 of 88-92% 3, 6.
- Steroids: Steroids can improve several outcomes during an acute COPD exacerbation, and a 10- to 14-day course may be appropriate 3.
- Antibiotics: Antibiotic use has been shown to be beneficial, especially for patients with severe exacerbation 3.
- Noninvasive positive pressure ventilation: Noninvasive positive pressure ventilation may benefit a group of patients with rapid decline in respiratory function and gas exchange 3, 6.