What is the full inpatient management of a 65-year-old woman with Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

Inpatient Management of COPD Exacerbation in a 65-Year-Old Woman

The comprehensive inpatient management of a 65-year-old woman with COPD exacerbation should include oxygen therapy targeting SpO2 of 88-92%, bronchodilators (short-acting β-agonists and anticholinergics), systemic corticosteroids (prednisone 30-40mg daily for 5-14 days), appropriate antibiotics if indicated, and early consideration of non-invasive ventilation for respiratory failure. 1, 2

Initial Assessment and Monitoring

• Assess severity of exacerbation:

  • Respiratory rate, use of accessory muscles, paradoxical breathing
  • Mental status changes
  • Hemodynamic stability
  • Presence of cyanosis

• Laboratory and diagnostic tests:

  • Arterial blood gas (ABG) to assess PaO2, PaCO2, and pH
  • Complete blood count
  • Basic metabolic panel
  • Chest radiography to rule out pneumonia or pneumothorax
  • Sputum culture if purulent sputum is present
  • ECG to assess for cardiac complications

Oxygen Therapy

• Target SpO2 of 88-92% or PaO2 around 60 mmHg to prevent tissue hypoxia while avoiding CO2 retention 1
• Use controlled oxygen delivery devices (Venturi mask) rather than high-flow systems
• Monitor ABGs within 30-60 minutes of initiating oxygen therapy to assess for CO2 retention
• Adjust oxygen settings based on ABG results and continuous SpO2 monitoring

Pharmacological Management

Bronchodilators

• Short-acting bronchodilators:

  • Combination of short-acting β-agonist (salbutamol/albuterol) and anticholinergic (ipratropium)
  • Administer via metered-dose inhaler (MDI) with spacer or nebulizer every 2-4 hours 1
  • Consider continuous nebulization for severe symptoms

• Consider adding long-acting bronchodilators during hospitalization to prepare for discharge regimen 1

Corticosteroids

• Systemic corticosteroids: Prednisone 30-40 mg orally daily for 5-14 days 1, 2
• If unable to take oral medications, equivalent intravenous dose
• Taper not necessary for short courses (5-7 days)

Antibiotics

• Indicated when there is:

  • Increased sputum purulence
  • Increased sputum volume
  • Increased dyspnea 3

• Antibiotic selection based on local resistance patterns:

  • First-line: Amoxicillin, doxycycline, or macrolides
  • If failed prior therapy: Amoxicillin/clavulanate or respiratory fluoroquinolones 1
  • Duration: 5-7 days

Ventilatory Support

• Non-invasive ventilation (NIV) should be initiated early if:

  • Respiratory acidosis (pH < 7.35 with PaCO2 > 45 mmHg)
  • Severe dyspnea with clinical signs of respiratory muscle fatigue
  • Persistent hypoxemia despite supplemental oxygen 1, 2

• Mechanical ventilation considerations if NIV fails:

  • Worsening acidosis or hypoxemia
  • Deteriorating mental status
  • Hemodynamic instability
  • Inability to clear secretions

Adjunctive Therapies

• Fluid management:

  • Ensure adequate hydration
  • Monitor for signs of heart failure
  • Consider diuretics if fluid overload is present

• Deep vein thrombosis prophylaxis:

  • Subcutaneous heparin or low molecular weight heparin 1

• Nutritional support:

  • Assess nutritional status
  • Provide supplements for malnourished patients 1, 2

• Airway clearance techniques:

  • Encourage effective coughing
  • Consider chest physiotherapy for patients with copious secretions

Monitoring and Reassessment

• Frequent reassessment of respiratory status, vital signs, and oxygen requirements
• Daily assessment of symptoms, medication response, and potential for step-down care
• Monitor for complications:
  • Pneumonia
  • Respiratory failure
  • Cardiac arrhythmias
  • Pulmonary embolism

Discharge Planning and Transition of Care

• Begin discharge planning early during hospitalization
• Ensure appropriate outpatient medications are prescribed
• Verify proper inhaler technique before discharge
• Schedule follow-up appointment within 4-6 weeks 4
• Consider pulmonary rehabilitation referral 2
• Provide vaccination if needed (influenza, pneumococcal) 1, 2
• Smoking cessation counseling if applicable 2

Special Considerations for Older Patients

• Medication adjustments:

  • Consider age-related changes in pharmacokinetics
  • Assess for drug-drug interactions with existing medications
  • Monitor for adverse effects more closely 5

• Comorbidity management:

  • Address cardiovascular disease, diabetes, osteoporosis
  • Adjust treatment approach based on comorbidities

Common Pitfalls to Avoid

• Excessive oxygen administration leading to hypercapnic respiratory failure
• Delayed initiation of NIV in appropriate candidates
• Inadequate bronchodilator therapy or improper inhaler technique
• Premature discharge before clinical stability is achieved
• Failure to address smoking cessation as part of comprehensive management

By following this structured approach to the inpatient management of COPD exacerbation, clinicians can optimize outcomes for this 65-year-old woman, reducing mortality risk and improving quality of life after discharge.