What are the treatment dosages and management steps for AECOPD, CAP, bronchitis, PE, pneumothorax, cardiac ischemia, and severe asthma exacerbation?

Treatment Dosages and Management Steps for Common Respiratory and Cardiac Emergencies

Acute Exacerbation of COPD (AECOPD)

For AECOPD management, use short-acting bronchodilators, systemic corticosteroids, and antibiotics when appropriate, with oxygen titrated to 88-92% saturation to prevent both hypoxemia and hyperoxemia-related complications. 1

Bronchodilators:

• Short-acting bronchodilators: First-line treatment
  • Combine β2-agonists (albuterol/salbutamol) and anticholinergics (ipratropium)
  • Administer via spacer devices or air-driven nebulizers with supplemental oxygen

Corticosteroids:

• Oral corticosteroids: Equally effective as IV for hospitalized patients 1
  • Prednisone 40mg daily for 5 days
  • Alternative: Methylprednisolone 60-125mg IV if unable to take oral medications

Antibiotics:

• For patients with increased sputum purulence plus increased dyspnea and/or volume:
  • Azithromycin: 500mg daily for 3 days OR 500mg on day 1, then 250mg daily for days 2-5 2
  • Alternative: Amoxicillin/clavulanate 875/125mg twice daily for 5-7 days

Oxygen Therapy:

• Target oxygen saturation: 88-92% 1, 3
• Monitor arterial blood gases within 60 minutes if initially acidotic or hypercapnic

Ventilatory Support:

• Non-invasive ventilation (NIV): First option for respiratory failure
  • Consider when pH <7.26, rising PaCO₂, or failure to respond to supportive treatment
  • Initial settings: IPAP 10-12 cmH₂O, EPAP 4-5 cmH₂O, titrate as needed

Community-Acquired Pneumonia (CAP)

Outpatient Treatment:

• Previously healthy, no risk factors for drug-resistant pathogens:

  • Amoxicillin 1g three times daily for 5 days OR
  • Doxycycline 100mg twice daily for 5 days

• Comorbidities or risk factors for drug-resistant pathogens:

  • Amoxicillin/clavulanate 875/125mg twice daily plus azithromycin 500mg on day 1, then 250mg daily for days 2-5 OR
  • Levofloxacin 750mg daily for 5 days

Inpatient Treatment (non-ICU):

• Combination therapy:
  • Ceftriaxone 1-2g IV daily plus azithromycin 500mg IV/PO daily OR
  • Levofloxacin 750mg IV/PO daily

Inpatient Treatment (ICU):

• Combination therapy:
  • Ceftriaxone 2g IV daily plus azithromycin 500mg IV daily OR
  • Ceftriaxone 2g IV daily plus levofloxacin 750mg IV daily

Acute Bronchitis

• Primarily supportive care as most cases are viral
• Bronchodilators for wheezing/cough:
  • Albuterol MDI 2 puffs every 4-6 hours as needed
• Antitussives for severe cough:
  • Dextromethorphan 10-30mg every 4-6 hours as needed
• Antibiotics generally not recommended unless evidence of bacterial infection

Pulmonary Embolism (PE)

Anticoagulation:

• Initial therapy:

  • Unfractionated heparin: 80 units/kg IV bolus, then 18 units/kg/hour infusion, adjust to target aPTT 1.5-2.5× control OR
  • Enoxaparin: 1mg/kg subcutaneously every 12 hours (adjust for renal impairment)
  • Fondaparinux: 5mg (<50kg), 7.5mg (50-100kg), or 10mg (>100kg) subcutaneously daily

• Transition to oral therapy:

  • Direct oral anticoagulants (preferred):
    • Rivaroxaban: 15mg twice daily for 21 days, then 20mg daily
    • Apixaban: 10mg twice daily for 7 days, then 5mg twice daily
  • Warfarin: Overlap with parenteral anticoagulation until INR 2-3 for at least 24 hours

Thrombolysis (for massive PE with hemodynamic instability):

• Alteplase: 100mg IV over 2 hours OR 50mg IV over 15 minutes in critical situations

Pneumothorax

Small, Primary Spontaneous Pneumothorax:

• Observation with supplemental oxygen
• Follow-up chest X-ray in 24 hours

Large or Symptomatic Pneumothorax:

• Needle aspiration: 16-18G angiocatheter at 2nd intercostal space, midclavicular line
• Chest tube: 14-20F tube at 4th-5th intercostal space, anterior axillary line
  • Connect to underwater seal drainage at -20 cmH₂O suction

Tension Pneumothorax:

• Immediate needle decompression: 14-16G angiocatheter at 2nd intercostal space, midclavicular line
• Follow with chest tube placement

Cardiac Ischemia

Initial Management:

• Oxygen: Only if saturation <90%
• Aspirin: 162-325mg chewed immediately
• Nitroglycerin: 0.4mg sublingual every 5 minutes for 3 doses, then reassess

STEMI Treatment:

• Reperfusion strategy:
  • Primary PCI (preferred): Door-to-balloon time <90 minutes
  • Fibrinolysis if PCI not available within 120 minutes:
    • Alteplase: 15mg IV bolus, then 0.75mg/kg (max 50mg) over 30 minutes, then 0.5mg/kg (max 35mg) over 60 minutes
    • Tenecteplase: Single IV bolus based on weight (30-50mg)

Antiplatelet/Anticoagulant Therapy:

• Dual antiplatelet therapy:
  • Aspirin 325mg loading dose, then 81mg daily
  • P2Y12 inhibitor:
    • Ticagrelor: 180mg loading dose, then 90mg twice daily
    • Prasugrel: 60mg loading dose, then 10mg daily
    • Clopidogrel: 600mg loading dose, then 75mg daily
• Anticoagulation:
  • Unfractionated heparin: 60 units/kg IV bolus (max 4000 units), then 12 units/kg/hour (max 1000 units/hour)

Severe Asthma Exacerbation

For severe asthma exacerbation, administer high-dose short-acting beta-agonists with ipratropium bromide, systemic corticosteroids, and consider magnesium sulfate for patients not responding to initial therapy. 4

Bronchodilators:

• Short-acting β2-agonists:
  • Albuterol nebulizer: 2.5-5mg every 20 minutes for 3 doses, then every 1-4 hours as needed OR
  • Albuterol MDI: 4-8 puffs every 20 minutes for up to 4 hours, then every 1-4 hours as needed
• Ipratropium bromide:
  • 0.5mg nebulized every 20 minutes for 3 doses, then every 2-4 hours as needed 4

Corticosteroids:

• Systemic corticosteroids (start within 1 hour of presentation):
  • Prednisone/prednisolone: 40-60mg daily for 5-7 days
  • Methylprednisolone: 60-125mg IV in divided doses
  • No taper needed for short courses (<10 days) 4

Additional Therapies:

• Magnesium sulfate: 2g IV over 20 minutes for severe exacerbations not responding to initial treatment 4
• Oxygen: Maintain saturation >92% (>95% for pregnant women and cardiac disease) 4

Ventilatory Support:

• Non-invasive ventilation: Consider for patients with fatigue or impending respiratory failure
• Intubation and mechanical ventilation:
  • Use low tidal volumes (6-8 mL/kg)
  • Permissive hypercapnia strategy
  • Longer expiratory times to prevent auto-PEEP

Discharge Criteria:

• Sustained response to bronchodilators (effect lasting >4 hours)
• Able to use inhalers correctly
• PEF or FEV1 >70% of predicted or personal best
• Oxygen saturation >90% on room air

Remember that early administration of appropriate treatments at adequate dosages is critical for preventing deterioration and improving outcomes in all these conditions.