When to discharge Chronic Obstructive Pulmonary Disease (COPD) patients?

From the Guidelines

Patients with COPD exacerbations should be discharged when they demonstrate clinical stability for at least 24 hours, including stable or improved symptoms, ability to use inhaler devices correctly, and no need for short-acting bronchodilators more than every 4 hours, as supported by the European Respiratory Society/American Thoracic Society guideline 1. This recommendation prioritizes morbidity, mortality, and quality of life as the outcome, considering the patient's ability to manage their condition and perform daily activities.

Key Considerations for Discharge

• Clinical stability for at least 24 hours
• Stable or improved symptoms
• Ability to use inhaler devices correctly
• No need for short-acting bronchodilators more than every 4 hours
• Oxygen saturation at or near the patient's baseline (typically >88-90% on room air or their usual oxygen flow rate)
• Ability to perform basic activities of daily living

Medications and Follow-up

Prior to discharge, ensure patients have appropriate medications, including:

• A short-acting bronchodilator (like albuterol)
• Long-acting bronchodilators (such as tiotropium 18mcg daily or salmeterol 50mcg twice daily)
• Inhaled corticosteroids (like fluticasone)
• A short course of oral corticosteroids (prednisone 40mg daily for 5 days) and antibiotics if a bacterial infection was suspected (commonly azithromycin 500mg on day 1, then 250mg daily for 4 more days) Patients should have a clear follow-up plan within 1-2 weeks, understand their medication regimen, demonstrate proper inhaler technique, and have addressed any social support needs, as suggested by the British Thoracic Society guideline 1 and the European Respiratory Society/American Thoracic Society guideline 1.

Home-Based Management

Home-based management programs, such as "hospital-at-home," can be an effective alternative to hospitalization for patients with COPD exacerbations, reducing hospital readmissions and potentially lowering mortality, as shown in the European Respiratory Society/American Thoracic Society guideline 1. However, patient selection should depend on the resources available and the absence of factors associated with a worse prognosis, such as acidosis, as recommended by the British Thoracic Society guideline 1. Early discharge planning is crucial to prevent hospital-acquired infections and deconditioning, while ensuring adequate stability prevents early readmissions due to incomplete recovery from the exacerbation.

From the Research

Discharge Criteria for COPD Patients

The decision to discharge a patient with Chronic Obstructive Pulmonary Disease (COPD) depends on various factors, including the patient's medical stability and ability to manage their condition at home.

• A study published in 2000 2 found that the need for long-term oxygen therapy should be determined when patients are medically stable, and that reevaluating patients 1-3 months after continuous oxygen therapy is initiated can help identify those who can be discontinued from therapy.
• Another study published in 2020 3 found that a personalized action plan introduced at or post-discharge can reduce readmissions and improve symptom burden in COPD patients.

Factors to Consider Before Discharge

Before discharging a COPD patient, healthcare professionals should consider the following factors:

• The patient's lung function and respiratory muscle function, as measured by parameters such as FEV1 and MIP 4
• The patient's ability to manage their condition at home, including their ability to use inhalation therapy and follow a personalized action plan 3
• The need for ongoing care and rehabilitation, including referral for pulmonary rehabilitation and advice on influenza vaccination 5

Discharge Bundle of Care

A discharge bundle of care can help ensure that COPD patients receive the necessary interventions and support before being discharged from the hospital.

• A study published in 2015 5 found that the introduction of a discharge bundle of care can help improve compliance with internationally agreed interventions and reduce readmissions.
• The bundle of care should include assessments of oxygen requirements, arrangements for follow-up, referral for pulmonary rehabilitation, and advice on influenza vaccination 5.