What is the recommended inpatient treatment plan for a Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

Inpatient Treatment Plan for COPD Exacerbation

The recommended inpatient treatment plan for COPD exacerbation includes short-acting bronchodilators, systemic corticosteroids for 5-7 days, antibiotics when indicated, supplemental oxygen targeting SpO2 of 88-92%, and consideration of noninvasive ventilation for respiratory failure. 1

Initial Assessment and Management

Oxygen Therapy

• Maintain PaO2 ≥8 kPa (60 mmHg) or SpO2 ≥90% to prevent tissue hypoxia 1
• Use nasal cannula or venturi mask for delivery
• Target SpO2 of 88-92% to avoid CO2 retention 2
• Monitor arterial blood gases for PaO2, PaCO2, and pH in severe exacerbations

Bronchodilator Therapy

• First-line treatment: Short-acting inhaled β2-agonists (e.g., salbutamol/albuterol) with or without short-acting anticholinergics (e.g., ipratropium) 1
• Dosing: MDI with spacer, two puffs every 2-4 hours or via nebulizer 1
• No significant differences in efficacy between MDI with spacer and nebulizer delivery 1
• Avoid intravenous methylxanthines due to side effect profiles 1

Pharmacological Treatment

Corticosteroids

• Systemic corticosteroids: Prednisone 40 mg orally daily for 5-7 days 1
• If patient cannot tolerate oral medications, equivalent dose intravenously 1
• Oral prednisolone is equally effective as intravenous administration 1
• Benefits include improved lung function, oxygenation, shorter recovery time, and reduced hospitalization duration 1

Antibiotics

• Indicated when patient has increased sputum purulence plus either increased dyspnea or increased sputum volume 1
• Duration: 5-7 days 1
• Options based on local bacterial resistance patterns:
  • Amoxicillin/clavulanate
  • Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin)
  • Consider combination therapy if Pseudomonas or other Enterobacteriaceae are suspected 1

Advanced Respiratory Support

Noninvasive Ventilation (NIV)

• First-line ventilation mode for patients with acute respiratory failure without contraindications 1
• Benefits: Improves gas exchange, reduces work of breathing, decreases need for intubation, shortens hospitalization, and improves survival 1
• Indications for ICU or specialized care unit admission:
  • Impending or actual respiratory failure
  • Presence of other end-organ dysfunction
  • Hemodynamic instability 1

Monitoring and Follow-up

During Hospitalization

• Monitor vital signs, oxygen saturation, and work of breathing
• Assess response to therapy
• Evaluate for complications or comorbidities
• Consider pulmonary rehabilitation after stabilization (but not during acute hospitalization) 1

Prior to Discharge

• Ensure stability of respiratory symptoms
• Verify patient can use inhaler devices correctly
• Review maintenance medications
• Arrange follow-up within 2 weeks

Common Pitfalls to Avoid

1. Excessive oxygen administration: Can lead to CO2 retention and respiratory acidosis in COPD patients; target SpO2 88-92% rather than normalizing 1

2. Prolonged corticosteroid therapy: Limit to 5-7 days to reduce side effects while maintaining benefits 1

3. Overuse of antibiotics: Reserve for patients with purulent sputum and increased dyspnea or sputum volume 1

4. Relying on methylxanthines: These have a narrow therapeutic index and significant side effects; avoid as first-line therapy 1

5. Delaying NIV: Early implementation of NIV in appropriate patients reduces need for intubation and improves outcomes 1

By following this evidence-based approach to managing COPD exacerbations, clinicians can effectively reduce morbidity, mortality, and improve quality of life for patients requiring inpatient care.