What are the admitting orders for a patient with an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD)?

Admitting Orders for Acute Exacerbation of COPD

The standard admitting orders for a patient with acute exacerbation of COPD should include oxygen therapy with target saturation of 88-92%, short-acting bronchodilators, systemic corticosteroids, antibiotics if indicated, and appropriate monitoring of respiratory status. 1, 2

Initial Assessment and Monitoring

• Obtain arterial blood gases on arrival and repeat 30-60 minutes after initiating oxygen therapy 2
• Monitor oxygen saturation continuously with pulse oximetry 1, 2
• Check blood gases if clinical deterioration occurs, even if initial PCO2 was normal 2
• Consider spirometry at least once during admission if this is the patient's first presentation with presumed COPD 2

Oxygen Therapy

• Prescribe controlled oxygen therapy with target saturation of 88-92% 1, 2
• Use 24% Venturi mask at 2-3 L/min, nasal cannulae at 1-2 L/min, or 28% Venturi mask at 4 L/min 2
• For nebulizer treatments, use compressed air to drive nebulizers if the patient has hypercapnia and/or respiratory acidosis 1
• Continue oxygen via nasal prongs at 1-2 L/min during nebulization to prevent desaturation 1

Bronchodilator Therapy

• Order short-acting beta-2 agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) via nebulizer 1
• Add anticholinergic (ipratropium bromide 0.25-0.5 mg) via nebulizer 1
• Administer nebulized bronchodilators every 4-6 hours initially, may be used more frequently if required 1
• After 24-48 hours or when patient is improving, transition to metered dose inhaler or dry powder inhaler 1

Corticosteroid Therapy

• Prescribe oral prednisolone 30 mg daily for 5-7 days 1, 3
• For patients unable to take oral medications, order intravenous hydrocortisone 100 mg every 6 hours 3
• Plan to discontinue corticosteroids after the acute episode (usually 7-14 days) unless there is a definite indication for long-term treatment 1, 3
• Transition from intravenous to oral corticosteroids as soon as the patient can tolerate oral medications 3

Antibiotic Therapy

• Prescribe antibiotics for patients with increased dyspnea, increased sputum volume, and increased sputum purulence 2, 4
• For mild to moderate exacerbations, order one of the following:
  • Amoxicillin/ampicillin 1
  • Doxycycline 1
  • Trimethoprim-sulfamethoxazole 4
  • Amoxicillin-clavulanate 1, 4
• For severe exacerbations or treatment failures, consider:
  • Respiratory fluoroquinolones 1
  • Third-generation cephalosporins 4
• Duration of antibiotic therapy should be 5-7 days 2

Additional Medications

• Consider intravenous methylxanthines (aminophylline 0.5 mg/kg/hour) by continuous infusion if patient is not responding to standard therapy 1
• If methylxanthines are used, monitor blood levels daily 1
• Order diuretics if peripheral edema and raised jugular venous pressure are present 1
• Consider prophylactic subcutaneous heparin for patients with acute respiratory failure 1

Ventilatory Support

• Initiate non-invasive ventilation (NIV) if respiratory acidosis persists (pH < 7.26) despite standard medical management 1
• Consider high-flow nasal cannula oxygen therapy as an alternative in selected patients 2, 5

Discharge Planning

• Begin early rehabilitation during hospitalization 2, 5
• Plan for influenza and pneumococcal vaccination if not up to date 4
• Schedule follow-up pulmonary function testing 4

Common Pitfalls to Avoid

• Avoid uncontrolled high-flow oxygen which may worsen hypercapnia 6
• Do not continue corticosteroids beyond 7-14 days unless specifically indicated 3
• Avoid prolonged courses of antibiotics beyond 7 days 3, 2
• Do not routinely use chest physiotherapy during acute exacerbations 1
• Avoid using intravenous corticosteroids when oral administration is possible, as IV route has higher risk of adverse effects 3