Is it recommended to continue home inhalers in the treatment of Chronic Obstructive Pulmonary Disease (COPD) exacerbation as an inpatient?

Continuing Home Inhalers During COPD Exacerbation Hospitalization

Yes, home inhalers should be continued during hospitalization for COPD exacerbation, with short-acting bronchodilators added as needed for symptom relief. 1

Rationale for Continuing Home Inhalers

The British Thoracic Society (BTS) guidelines clearly support the continuation of bronchodilator therapy during COPD exacerbations. Short-acting bronchodilators (beta-agonists or anticholinergics) are effective in increasing FEV1 and reducing breathlessness during exacerbations, but this doesn't mean home maintenance inhalers should be discontinued 1.

Key reasons to continue home inhalers:

1. Maintenance of baseline bronchodilation: Long-acting bronchodilators (LABAs/LAMAs) provide sustained bronchodilation that complements the acute relief from short-acting agents

2. Preventing withdrawal effects: Abrupt discontinuation of maintenance therapy may lead to worsening symptoms

3. Continuity of care: Maintaining the patient's established regimen ensures smoother transition back to outpatient management

Treatment Algorithm for Inpatient COPD Exacerbation Management

Step 1: Initial Assessment (First 24 Hours)

• Continue all home inhalers (LABA, LAMA, ICS combinations) at their regular schedule
• Add short-acting bronchodilators (beta-agonists and/or anticholinergics) for acute symptom relief
• Short-acting bronchodilators can be administered via nebulizer or MDI with spacer based on patient's ability to use devices 1

Step 2: Ongoing Management (24-48 Hours)

• Continue home maintenance inhalers (LABA/LAMA or LABA/ICS combinations)
• Adjust frequency of short-acting bronchodilators based on symptom response
• Add systemic corticosteroids (prednisolone 30 mg daily for 7-14 days) 1
• Add antibiotics if indicated (purulent sputum, increased sputum volume, increased breathlessness) 1

Step 3: Transition to Discharge (>48 Hours)

• Continue maintenance inhalers
• Reduce frequency of short-acting bronchodilators as symptoms improve
• Ensure proper inhaler technique before discharge

Administration Considerations

The BTS guidelines note that bronchodilators can be effectively administered by either nebulizers or hand-held inhalers during exacerbations 1. The choice should be based on:

1. Patient's ability: If the patient cannot effectively use an inhaler during acute distress, nebulized therapy may be preferred

2. Convenience: Nebulized treatments may be more convenient in the hospital setting as they require less supervision than multiple MDI inhalations 1

3. Return to baseline: As the patient improves, transition back to their home inhaler devices to ensure proper technique before discharge

Common Pitfalls to Avoid

1. Discontinuing maintenance therapy: Some clinicians mistakenly stop home inhalers when initiating nebulized therapy, creating a gap in maintenance treatment

2. Device confusion: Ensure proper technique is maintained when switching between delivery devices

3. Medication duplication: Be cautious about inadvertently doubling bronchodilator therapy (e.g., continuing a LABA inhaler while adding nebulized LABA)

4. Inadequate transition planning: Failure to ensure the patient can properly use their home inhalers before discharge increases risk of readmission

Special Considerations

For patients with severe COPD exacerbations, the FDA labels for maintenance inhalers like salmeterol and formoterol indicate that if shortness of breath occurs between doses, a short-acting beta-agonist should be used for immediate relief 2, 3. This supports the approach of continuing maintenance therapy while adding rescue medication.

In summary, home inhalers should be continued during hospitalization for COPD exacerbation, with appropriate additions of short-acting bronchodilators, systemic corticosteroids, and antibiotics as needed based on the patient's clinical presentation.