What are the management strategies for an inpatient with chronic obstructive pulmonary disease (COPD) exacerbation who has had a recent admission for COPD exacerbation?

From the Guidelines

For inpatient management of a COPD exacerbation in a patient with a recent admission, implement an aggressive treatment regimen focusing on bronchodilation, anti-inflammation, and supportive care, as recommended by the most recent guidelines 1.

Key Components of Management

• Start with frequent nebulized short-acting bronchodilators: albuterol 2.5 mg and ipratropium 0.5 mg every 4-6 hours, as suggested by previous studies 1.
• Administer systemic corticosteroids, preferably oral prednisone 40 mg daily for 5 days, to reduce airway inflammation and improve lung function 1.
• If the patient has purulent sputum or signs of infection, prescribe antibiotics such as azithromycin 500 mg daily for 3 days or doxycycline 100 mg twice daily for 5 days, as recommended by the guidelines 1.

Supportive Care and Prevention of Future Exacerbations

• Provide supplemental oxygen to maintain SpO2 between 88-92%, and consider non-invasive ventilation if the patient has persistent hypercapnia (PaCO2 > 45 mmHg) with respiratory acidosis (pH < 7.35) 1.
• Assess for and treat any underlying causes of the exacerbation, such as pneumonia or heart failure.
• Given the recent admission, intensify the treatment plan by adding a long-acting bronchodilator like tiotropium 18 mcg inhaled daily, if not already prescribed, to reduce the risk of future exacerbations 1.
• Ensure proper inhaler technique and consider spacer use.
• Initiate pulmonary rehabilitation as soon as the patient is stable, as recommended by the guidelines 1.

Discharge Planning

• Before discharge, optimize maintenance therapy, provide a written action plan, and arrange early follow-up within 1-2 weeks.
• This aggressive approach aims to break the cycle of frequent exacerbations by providing maximal bronchodilation, reducing airway inflammation, and addressing any infectious triggers, thereby improving lung function and preventing readmission, as emphasized by the most recent guidelines 1.

From the FDA Drug Label

The effect of roflumilast 500 mcg once daily on COPD exacerbations was evaluated in five 1-year trials (Trials 3,4,5,6 and 9).

Exploratory analyses of the results of Trials 3 and 4 identified a subpopulation of patients with severe COPD associated with chronic bronchitis and COPD exacerbations within the previous year that appeared to demonstrate a better response in the reduction of the rate of COPD exacerbations compared to the overall population

Two subsequent trials (Trial 5 and Trial 6) were conducted that enrolled patients with severe COPD but associated with chronic bronchitis, at least one COPD exacerbation in the previous year, and at least a 20 pack-year smoking history

The management strategies for an inpatient with COPD exacerbation who has had a recent admission for COPD exacerbation may include the use of roflumilast to reduce the rate of moderate or severe exacerbations. Key points to consider are:

• Severe COPD associated with chronic bronchitis and a history of COPD exacerbations in the previous year
• Roflumilast 500 mcg once daily demonstrated a significant reduction in the rate of moderate or severe exacerbations compared to placebo in two trials (Trial 5 and Trial 6) 2
• The use of long-acting beta agonists, short-acting anti-muscarinics, and inhaled corticosteroids may be allowed as concomitant medications or rescue therapy.

From the Research

Management Strategies for COPD Exacerbation

The management of COPD exacerbations in hospitalized patients involves a comprehensive approach, including pharmacologic and non-pharmacologic interventions. Some key strategies include:

• Targeted O2 therapy, titrated to an SpO2 of 88-92% 3
• Inhaled short-acting bronchodilators, which can be provided by various devices such as nebulizers, pressurized metered-dose inhalers, or dry powder inhalers 3
• Systemic corticosteroids and antibiotics, which are commonly used to treat COPD exacerbations 4, 5
• Noninvasive ventilation (NIV), which is a standard therapy for patients with COPD exacerbation 3

Multidisciplinary Approach

A multidisciplinary team, including hospitalists, respiratory therapists, and other healthcare professionals, plays a crucial role in managing COPD exacerbations. This team should:

• Conduct comprehensive screening and diagnostic testing at admission to accurately diagnose COPD exacerbations and assess severity 4
• Develop a personalized treatment plan, including pharmacotherapy, oxygen and/or ventilatory support, and education on medication use and inhalation devices 4, 6
• Ensure effective communication and care coordination, including transfer of discharge summaries to primary care physicians and scheduling of follow-up appointments 4, 6

Discharge Planning and Follow-up

Discharge planning and follow-up are critical components of COPD exacerbation management. Strategies include:

• Providing patients with appropriate maintenance therapy and counseling on medication use and inhalation devices 4, 6
• Discussing smoking cessation and vaccinations with patients 4
• Using a COPD discharge bundle, which may include treatments such as smoking cessation, personalized pharmacotherapy, and non-pharmacotherapy like pulmonary rehabilitation 6, 7
• Identifying low-risk patients who may be suitable for domiciliary care or other alternative models of care 6