What are the management strategies for Chronic Obstructive Pulmonary Disease (COPD) inpatients?

From the Guidelines

Inpatient management of COPD exacerbations should prioritize the administration of systemic corticosteroids, such as prednisone 40 mg orally daily for 5 days, and non-invasive mechanical ventilation for patients with acute or acute-on-chronic respiratory failure, as recommended by the European Respiratory Society/American Thoracic Society guideline 1. The management of COPD exacerbations in the inpatient setting requires a multifaceted approach to address the underlying pathophysiology and prevent complications.

• Bronchodilators, such as albuterol and ipratropium, should be administered promptly to alleviate bronchospasm.
• Systemic corticosteroids are essential to reduce inflammation and improve outcomes, with oral administration preferred over intravenous if gastrointestinal access and function are intact 1.
• Antibiotics should be given if there are signs of bacterial infection, with common regimens including amoxicillin-clavulanate, doxycycline, or azithromycin.
• Supplemental oxygen should be titrated to maintain SpO2 88-92% to prevent hypercapnia while addressing hypoxemia, as guided by arterial blood gas measurements in patients with pre-existing COPD complicated by ventilatory failure 1.
• Non-invasive ventilation (NIV) should be considered for patients with respiratory acidosis (pH < 7.35 and PaCO2 > 45 mmHg) to reduce intubation rates, as recommended by the European Respiratory Society/American Thoracic Society guideline 1.
• Thromboprophylaxis with enoxaparin or heparin is important for immobilized patients to prevent venous thromboembolism.
• Before discharge, ensure the patient can use inhalers correctly, has appropriate outpatient medications, and receives smoking cessation counseling if applicable. The most recent and highest quality study, published in 2021, highlights the importance of pharmacologic management of COPD exacerbations, including the use of corticosteroids, systemic antibiotics, inhaled bronchodilators, and supplemental oxygen 1. However, the European Respiratory Society/American Thoracic Society guideline 1 provides more specific recommendations for inpatient management, which should be prioritized to improve outcomes and reduce morbidity and mortality.

From the FDA Drug Label

In controlled 12-week studies in patients with bronchospasm associated with chronic obstructive pulmonary disease (chronic bronchitis and emphysema) significant improvements in pulmonary function (FEV1 increases of 15% or more) occurred within 15 to 30 minutes, reached a peak in 1 to 2 hours, and persisted for periods of 4 to 5 hours in the majority of patients, with about 25% to 38% of the patients demonstrating increases of 15% or more for at least 7 to 8 hours. Combined therapy produced significant additional improvement in FEV1 and FVC On combined therapy, the median duration of 15% improvement in FEV1 was 5 to 7 hours, compared with 3 to 4 hours in patients receiving a beta agonist alone. In patients with chronic obstructive pulmonary disease (COPD), clinical studies have shown that theophylline decreases dyspnea, air trapping, the work of breathing, and improves contractility of diaphragmatic muscles with little or no improvement in pulmonary function measurements.

COPD Inpatient Management:

• Ipratropium bromide can be used to improve pulmonary function in patients with COPD, with significant improvements in FEV1 and FVC 2.
• Theophylline can be used to decrease dyspnea, air trapping, and the work of breathing in patients with COPD, although it may not improve pulmonary function measurements 3.
• Combination therapy of ipratropium bromide and a beta agonist can produce significant additional improvement in FEV1 and FVC, with a longer duration of action compared to a beta agonist alone 2.
• Key considerations for inpatient management of COPD include:
  • Monitoring of pulmonary function and symptoms
  • Adjustment of medication doses and regimens as needed
  • Consideration of combination therapy for optimal symptom control 2, 3

From the Research

COPD Inpatient Management Overview

• COPD exacerbations can cause significant morbidity and mortality, making effective management crucial for patient care 4
• Key components of acute therapy for COPD exacerbations include oral steroids, antibiotics, nebulizers, oxygen, and early consideration of noninvasive ventilation 5

Oxygen Therapy in COPD Management

• European and British guidelines endorse oxygen target saturations of 88%-92% for hospitalized patients with COPD exacerbation, with adjustment to 94%-98% if carbon dioxide levels are normal 6
• Oxygen saturations above 92% have been associated with higher mortality, and even modest elevations above this range can increase the risk of death 6
• Long-term oxygen therapy (LTOT) at home has been shown to improve survival in patients with COPD and severe resting hypoxemia 7

Pharmacologic and Non-Pharmacologic Strategies

• Inhaled bronchodilators, systemic steroids, antibiotics, and pulmonary rehabilitation are essential components of COPD management 4
• Multidisciplinary disease-management programs, including follow-up appointments, aftercare, inhaler training, and patient education, can reduce hospitalizations and readmissions for patients with COPD 8
• Timely and appropriate maintenance pharmacotherapy, particularly dual bronchodilators, can significantly reduce exacerbations in patients with COPD 8

Hospitalization and Readmission Reduction

• COPD exacerbations are a major cause of high 30-day hospital readmission rates, with healthcare costs associated with severe exacerbation-related hospitalization ranging from $7,000 to $39,200 8
• Strategies to improve patient care and reduce hospitalizations and readmissions include maximizing bronchodilation, multidisciplinary disease-management programs, and patient education 8