What are the typical medications and dosing for a patient admitted with a chronic obstructive pulmonary disease (COPD) exacerbation?

Standard Admission Orders for COPD Exacerbation

For patients admitted with COPD exacerbation, the standard medication regimen should include nebulized bronchodilators (both β-agonist and anticholinergic), systemic corticosteroids, antibiotics, and controlled oxygen therapy, with specific dosing and frequency as outlined below. 1

Oxygen Therapy

• Initial oxygen therapy: 24-28% via Venturi mask or 1-2 L/min via nasal cannula
• Target: PaO₂ >7.5 kPa (>60 mmHg) without causing respiratory acidosis
• Check arterial blood gases within 60 minutes of starting oxygen and after any change in concentration
• If patient is hypercapnic or acidotic, use compressed air to drive nebulizers with supplemental oxygen via nasal cannula at 1-2 L/min during treatments 1

Bronchodilator Therapy

Nebulized Medications

• β-agonist: Salbutamol 2.5-5 mg OR Terbutaline 5-10 mg
• Anticholinergic: Ipratropium bromide 0.25-0.5 mg
• Frequency: Every 4-6 hours initially; may be given more frequently if needed
• For severe exacerbations: Combine both medications in the same nebulizer treatment 1
• Continue nebulized treatments for 24-48 hours or until clinical improvement

Transition to Inhalers

• After 24-48 hours of clinical improvement, transition to metered-dose inhalers or dry powder inhalers
• Observe patient for 24-48 hours after transition before discharge 1

Corticosteroids

• Oral: Prednisolone 30 mg daily for 7-14 days
• IV alternative (if oral route not possible): Hydrocortisone 100 mg IV every 6 hours 1
• Discontinue after the acute episode unless specifically indicated for long-term use

Antibiotics

• First-line: Amoxicillin 500 mg PO TID OR Tetracycline 500 mg PO QID for 5-7 days
• Second-line (for more severe exacerbations or poor response to first-line):
  • Broad-spectrum cephalosporin OR
  • Macrolide (e.g., Azithromycin 500 mg daily for 3 days) 1, 2

Additional Medications (as indicated)

Methylxanthines

• Consider if inadequate response to nebulized bronchodilators
• Aminophylline 0.5 mg/kg/hour continuous IV infusion
• Monitor daily theophylline levels (target: 5-15 μg/mL) 1

Diuretics

• Indicated only if peripheral edema and elevated jugular venous pressure 1

Thromboprophylaxis

• Subcutaneous heparin for patients with acute-on-chronic respiratory failure 1

Monitoring Parameters

• Vital signs including respiratory rate
• Oxygen saturation (continuous monitoring if unstable)
• Arterial blood gases if:
  • Initial PaO₂ <60 mmHg
  • PaCO₂ >45 mmHg
  • pH <7.35
  • Clinical deterioration
• Daily assessment of bronchodilator response

Important Considerations

1. Nebulizer delivery: If patient has hypercapnia or respiratory acidosis, use compressed air (not oxygen) to drive nebulizers 1

2. Ventilatory support: Consider non-invasive ventilation (NIPPV) if pH <7.26 with rising PaCO₂ despite optimal medical therapy 1

3. Avoid routine chest physiotherapy as it is not recommended in acute COPD exacerbations 1

4. Common pitfalls to avoid:

   • Excessive oxygen administration leading to worsening hypercapnia
   • Inadequate bronchodilator frequency in severe exacerbations
   • Premature discontinuation of systemic corticosteroids
   • Failure to transition from nebulizers to inhalers before discharge

This medication regimen is based on the British Thoracic Society guidelines for management of COPD exacerbations, which provide the most comprehensive recommendations for inpatient management of these patients 1.