What is the full inpatient management of Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

Inpatient Management of COPD Exacerbation

The comprehensive inpatient management of COPD exacerbation requires controlled oxygen therapy, bronchodilators, systemic corticosteroids, antibiotics when indicated, and consideration of ventilatory support for respiratory failure, with early discharge planning to prevent readmissions. 1

Initial Assessment and Triage

• Evaluate severity of exacerbation:

  • Respiratory status: respiratory rate, use of accessory muscles, paradoxical breathing
  • Oxygenation: SpO2, arterial blood gases (ABGs)
  • Mental status changes
  • Hemodynamic stability 2

• Indications for hospitalization:

  • Severe dyspnea not responding to initial therapy
  • Hypoxemia (PaO2 <60 mmHg) or hypercapnia (PaCO2 >50 mmHg)
  • Altered mental status
  • Inability for self-care or inadequate home support
  • Significant comorbidities
  • Failed outpatient management 2, 1

• Indications for ICU admission:

  • Impending or actual respiratory failure
  • Hemodynamic instability
  • End-organ dysfunction (shock, renal, liver, or neurological disturbance) 2

Pharmacological Management

Oxygen Therapy

• Goal: Maintain PaO2 ~8 kPa (60 mmHg) or SpO2 ~90%
• Method: Controlled oxygen delivery via Venturi mask or nasal cannula
• Caution: Avoid hyperoxia as it may worsen hypercapnia in COPD patients
• Monitoring: Regular ABGs to monitor PaO2, PaCO2, and pH 2, 1

Bronchodilators

• First-line: Short-acting inhaled β2-agonists (e.g., salbutamol/albuterol) with or without short-acting anticholinergics (e.g., ipratropium)
• Delivery: Via nebulizer or metered-dose inhaler with spacer every 2-4 hours
• Dosing:
  • Salbutamol: 2.5-5 mg via nebulizer or 2-4 puffs via MDI with spacer every 2-4 hours
  • Ipratropium: 0.5 mg via nebulizer or 2-4 puffs via MDI with spacer every 2-4 hours 2, 1

Corticosteroids

• Indication: All patients with COPD exacerbation
• Regimen: Prednisone/prednisolone 40 mg daily for 5 days
• Route: Oral administration is equally effective as intravenous
• Benefits: Shortened recovery time, improved lung function, reduced risk of early relapse, decreased length of hospitalization
• Monitoring: Blood glucose levels, especially in diabetic patients 1

Antibiotics

• Indication: When at least two of the following are present:

  • Increased dyspnea
  • Increased sputum volume
  • Increased sputum purulence

• Duration: 5-7 days

• Options without Pseudomonas risk factors:

  • Co-amoxiclav
  • Doxycycline (100 mg daily for 5-7 days, with optional 200 mg loading dose on first day)
  • Respiratory fluoroquinolones (levofloxacin, moxifloxacin)

• Options with Pseudomonas risk factors:

  • Ciprofloxacin (preferred at 750 mg twice daily)
  • β-lactam with anti-pseudomonal activity ± aminoglycosides 1

Non-Pharmacological Management

Ventilatory Support

• Non-invasive ventilation (NIV) should be first-line for patients with:

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

• Benefits of NIV:

  • Improved gas exchange
  • Reduced work of breathing
  • Decreased need for intubation
  • Shortened hospitalization
  • Improved survival

• Invasive mechanical ventilation indications:

  • Failed NIV
  • Severe respiratory acidosis (pH <7.25)
  • Life-threatening hypoxemia
  • Cardiovascular instability
  • Impaired mental status/inability to protect airway 1

Fluid Management and Nutrition

• Ensure adequate hydration
• Monitor fluid balance
• Provide nutritional support, especially for malnourished patients
• Consider enteral nutrition for patients with prolonged ventilation 2

Monitoring and Follow-up

• Daily assessment of:

  • Symptoms (dyspnea, sputum)
  • Vital signs
  • Oxygen requirements
  • ABGs as indicated
  • Response to therapy

• Monitor for complications:

  • Pneumonia
  • Pneumothorax
  • Pulmonary embolism
  • Cardiac arrhythmias
  • Respiratory failure progression 2, 1

Discharge Planning

• Criteria for discharge:

  • Sustained response to bronchodilators
  • Correct inhaler technique
  • PEF or FEV1 >70% of predicted or personal best
  • Oxygen saturation >90% on room air
  • Stable comorbidities 1

• Pre-discharge interventions:

  • Initiate maintenance therapy with long-acting bronchodilators
  • For frequent exacerbators, consider LAMA/LABA combinations
  • Ensure proper inhaler technique and device selection
  • Smoking cessation counseling
  • Vaccination status review (influenza, pneumococcal)
  • Consider pulmonary rehabilitation referral 1, 3

• Follow-up timing:

  • Within 1-2 weeks after discharge
  • Monitor for worsening symptoms, decreasing oxygen saturation, altered mental status 1

Prevention of Future Exacerbations

• Maintenance therapy options:

  • LAMA/LABA combinations for frequent exacerbators
  • Consider adding inhaled corticosteroids for patients with blood eosinophilia or asthma history
  • Consider long-term macrolide therapy for patients with moderate to severe COPD who had exacerbations in the previous year despite optimal inhaler therapy 1

• Non-pharmacological prevention:

  • Pulmonary rehabilitation
  • Smoking cessation
  • Vaccination (influenza, pneumococcal)
  • Self-management education 1, 4

Special Considerations

• Hospital-at-home programs may be appropriate for selected patients:

  • No acute or acute-on-chronic ventilatory failure
  • No respiratory distress
  • No need for high-flow oxygen
  • Normal mental status
  • Adequate social support 2

• Common pitfalls to avoid:

  • Uncontrolled oxygen therapy leading to hypercapnic respiratory failure
  • Inadequate bronchodilator therapy
  • Premature discontinuation of corticosteroids
  • Failure to address comorbidities
  • Inadequate discharge planning leading to early readmission 1, 3

By following this comprehensive approach to inpatient management of COPD exacerbations, clinicians can optimize outcomes, reduce hospital length of stay, and minimize the risk of readmission.