What are the initial steps for managing Chronic Obstructive Pulmonary Disease (COPD) exacerbation, beyond giving oxygen at 5L/min to achieve an oxygen saturation of 92% and then reducing it to 2L/min, performing an Arterial Blood Gas (ABG), and starting nebulization with ipratropium bromide and a beta-agonist, such as salbutamol?

Management of COPD Exacerbation

For COPD exacerbation management, you should limit oxygen therapy to maintain saturation between 88-92%, perform arterial blood gas analysis before starting oxygen, use nebulized bronchodilators (both beta-agonists and anticholinergics), add systemic corticosteroids, and consider antibiotics if there are signs of infection. 1

Oxygen Therapy Protocol

• Initial oxygen should be limited to 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gas results are available 1
• Check blood gases within 60 minutes of starting oxygen and within 60 minutes of any change in inspired oxygen concentration 1
• Target oxygen saturation should be 88-92% for patients with COPD to avoid respiratory acidosis 1
• If PaO2 is responding without pH deterioration, gradually increase oxygen concentration until PaO2 is above 7.5 kPa 1
• If pH falls below 7.26 (due to rising PaCO2), consider alternative ventilation strategies 1
• For patients with hypercapnic respiratory failure, nebulizers should be driven by compressed air rather than oxygen 1

Bronchodilator Therapy

• Administer nebulized bronchodilators immediately on arrival and then at 4-6 hourly intervals (may be used more frequently if required) 1
• For moderate exacerbations, use either a beta-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) or an anticholinergic (ipratropium bromide 0.25-0.5 mg) 1
• For severe exacerbations, use both beta-agonist and anticholinergic agents together 1
• Continue nebulized bronchodilators for 24-48 hours or until clinical improvement, then switch to metered dose inhalers or dry powder inhalers 1

Systemic Corticosteroids

• Administer a 7-14 day course of systemic corticosteroids (prednisolone 30 mg/day orally or 100 mg hydrocortisone intravenously if oral route not possible) 1
• Discontinue corticosteroids after the acute episode unless there is a definite indication for long-term treatment 1

Antibiotic Therapy

• Prescribe antibiotics if there are signs of infection (purulent sputum, increased sputum volume, worsening dyspnea) 1, 2
• First-line antibiotics include amoxicillin or tetracycline unless these were used with poor response prior to admission 1
• For more severe exacerbations or poor response to first-line agents, consider broad-spectrum cephalosporins or newer macrolides 1
• Send sputum for culture if it appears purulent 1

Additional Measures

• Perform chest radiograph to rule out pneumonia or other complications 1
• Complete blood count, urea and electrolytes, and ECG should be done within the first 24 hours 1
• Consider diuretics if there is peripheral edema and raised jugular venous pressure 1
• Consider prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure 1
• If the patient is not responding to standard therapy, consider intravenous methylxanthines (aminophylline 0.5 mg/kg per hour) with daily monitoring of blood levels 1

Monitoring and Follow-up

• Repeat arterial blood gas measurements if the clinical situation deteriorates 1
• Monitor oxygen saturation continuously with pulse oximetry 1
• Record initial FEV1 and/or peak flow and start a serial peak flow chart 1
• Consider non-invasive ventilation (NIV) if the patient is hypercapnic (PCO2 >6 kPa) and acidotic (pH <7.35) after 30 minutes of standard medical management 1

Early Rehabilitation

• Consider early pulmonary rehabilitation following acute exacerbation as it can reduce re-exacerbation events requiring hospital admission 3

Discharge Planning

• Ensure the patient has adequate support to cope at home 1
• Ensure the patient understands the prescribed treatment and use of delivery devices 1
• Supply sufficient medication until the next opportunity for consultation 1
• Inform the patient's GP of the hospital visit within 48 hours 1