What is the recommended discharge medication regimen for a patient with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and difficulty breathing?

Discharge Medication Regimen for AECOPD

For a patient with AECOPD and scattered rhonchi post-nebulizer treatment, the recommended discharge medication regimen should include a short-acting beta-agonist MDI with spacer (such as salbutamol/albuterol) with two puffs every 2-4 hours as needed, plus consideration of ipratropium bromide MDI. 1

Bronchodilator Therapy

• Short-acting beta-agonist (SABA) via MDI with spacer should be the primary rescue medication, with dosing of 2 puffs every 2-4 hours as needed 1
• Consider adding ipratropium bromide MDI for patients with more severe symptoms or those who had poor response to beta-agonist alone during hospitalization 1
• MDI with spacer is as effective as nebulized therapy once the patient is stabilized, and facilitates earlier discharge from hospital 1
• Ensure proper MDI technique is taught and demonstrated by the patient before discharge 1

Corticosteroid Considerations

• If the patient received systemic corticosteroids during treatment, continue oral prednisone 30-40 mg daily to complete a 10-14 day course 1
• Consider adding inhaled corticosteroids by MDI for patients with frequent exacerbations 1

Antibiotic Therapy

• If antibiotics were started during treatment for purulent sputum or increased sputum volume, ensure the patient completes the full 5-7 day course 1
• Common antibiotics such as amoxicillin, tetracycline, or amoxicillin/clavulanate are usually sufficient unless there was poor response 1

Important Discharge Considerations

• Ensure the patient understands how to use the MDI with spacer correctly - technique should be taught and verified before discharge 1
• Transition from nebulizer to MDI should occur at least 24 hours prior to discharge to ensure stability on the discharge regimen 1
• Schedule follow-up within 30 days of discharge to reduce risk of readmission 1

Specific MDI Dosing Recommendations

• Salbutamol (albuterol): 2 puffs (90 μg/puff) every 2-4 hours as needed 1
• Ipratropium bromide: 2 puffs (18 μg/puff) every 4-6 hours as needed 2
• For patients requiring both medications, they can be administered separately or as a combination MDI if available 3, 4

Common Pitfalls to Avoid

• Failing to ensure proper MDI technique before discharge, which can lead to suboptimal medication delivery and treatment failure 1
• Continuing nebulized therapy at home when MDI with spacer would be equally effective and more convenient 5
• Not providing clear instructions about when to use rescue medications versus maintenance medications 1
• Overlooking the need for follow-up assessment within 30 days to evaluate response to therapy and adjust treatment as needed 1