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 controlled oxygen therapy targeting SpO2 88-92%, combination short-acting bronchodilators, systemic corticosteroids for 5-7 days, appropriate antibiotics, early consideration of non-invasive ventilation for respiratory failure, and comprehensive discharge planning to prevent readmission. 1
Initial Assessment and Diagnosis
Confirm COPD exacerbation diagnosis by assessing:
- Increased dyspnea
- Increased sputum volume
- Increased sputum purulence
- Increased wheeze and chest tightness
- Signs of fluid retention 2
Rule out differential diagnoses:
- Pneumonia
- Pneumothorax
- Left ventricular failure/pulmonary edema
- Pulmonary embolus
- Lung cancer
- Upper airway obstruction 2
Oxygen Therapy
- Target SpO2 of 88-92% or PaO2 around 60 mmHg
- Use controlled oxygen delivery devices (e.g., Venturi masks)
- Monitor arterial blood gases (ABGs) within 30-60 minutes of initiating oxygen therapy
- Avoid excessive oxygen administration which can worsen hypercapnia 1
Bronchodilator Therapy
Administer combination of short-acting bronchodilators:
- β-agonist (salbutamol/albuterol)
- Anticholinergic (ipratropium)
- Deliver via metered-dose inhaler (MDI) with spacer or nebulizer every 2-4 hours
- Consider continuous nebulization for severe symptoms 1
Consider adding long-acting bronchodilators during hospitalization to prepare for discharge regimen 1
Systemic Corticosteroids
- Administer prednisone 30-40 mg orally daily for 5-7 days
- No tapering necessary for short courses
- Monitor for adverse effects, especially in older patients 1
Antibiotic Therapy
Initiate antibiotics if two or more of the following are present:
- Increased breathlessness
- Increased sputum volume
- Development of purulent sputum 2
Select antibiotics based on local resistance patterns:
- First-line options: amoxicillin, doxycycline, or macrolides
- Second-line options: amoxicillin/clavulanate or respiratory fluoroquinolones if prior therapy has failed
- Treatment duration: 5-7 days 1
Non-Invasive Ventilation (NIV)
- Initiate NIV 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
Preventative Measures During Hospitalization
- Provide deep vein thrombosis prophylaxis using subcutaneous heparin or low molecular weight heparin
- Ensure adequate hydration
- Monitor for signs of heart failure; consider diuretics if fluid overload is present
- Assess nutritional status and provide supplements if malnourished
- Consider age-related changes in pharmacokinetics and potential drug interactions 1
Discharge Planning
- 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
- Consider pulmonary rehabilitation referral
- Provide vaccination if needed (influenza, pneumococcal) 1
Special Considerations for Older Women
- Monitor for osteoporosis risk, especially with corticosteroid use
- Assess for cardiovascular comorbidities which are common in this age group
- Consider lower initial doses of medications due to altered pharmacokinetics
- Ensure inhaler devices can be used effectively by the patient 3
Common Pitfalls to Avoid
- Excessive oxygen administration leading to CO2 retention
- Delayed initiation of NIV when indicated
- Inadequate bronchodilator therapy
- Premature discharge before clinical stability
- Failure to address smoking cessation
- Neglecting comorbidities that may complicate management 1