Management Plan for Severe COPD Exacerbation
For a patient with severe COPD exacerbation who is saturating well on 5L oxygen, already receiving continuous albuterol 20mg/hr and solumedrol, but does not tolerate prednisone, continue with intravenous methylprednisolone (solumedrol) as the primary corticosteroid treatment.
Initial Assessment and Monitoring
- Obtain arterial blood gases immediately to assess oxygenation and acid-base status, noting the inspired oxygen concentration 1
- Monitor oxygen saturation continuously with pulse oximetry 2
- Perform chest radiograph to rule out pneumonia or other complications 3
- Complete blood count, urea and electrolytes, and ECG within the first 24 hours 3
- Record initial FEV1 and/or peak flow and start a serial peak flow chart 3
Oxygen Therapy Management
- Maintain target oxygen saturation of 88-92% to avoid respiratory acidosis 1, 2
- If PaO2 is responding without pH deterioration, gradually increase oxygen concentration until PaO2 is above 7.5 kPa 3
- Repeat arterial blood gas measurements within 60 minutes of starting oxygen therapy and if clinical situation deteriorates 3
Bronchodilator Therapy
- Continue current albuterol (salbutamol) 20mg/hr continuous nebulization 3
- Add ipratropium bromide 0.25-0.5 mg via nebulizer for severe exacerbations 3
- Ensure nebulizers are driven by compressed air if the patient has hypercapnia and/or respiratory acidosis 3
- Continue nebulized bronchodilators for 24-48 hours or until clinical improvement, then switch to metered dose inhalers 3
Corticosteroid Management
- Continue intravenous methylprednisolone (solumedrol) since patient does not tolerate oral prednisone 4
- Recommended dosing is 30-40 mg IV daily for 10-14 days 3, 4
- Do not attempt to switch to oral prednisone given the patient's intolerance 5
- Consider transitioning to inhaled corticosteroids when appropriate before discharge 3
Antibiotic Therapy
- Prescribe antibiotics based on local bacterial resistance patterns 3
- First-line options include amoxicillin or tetracycline unless used with poor response prior to admission 3
- For more severe exacerbations, consider broad-spectrum cephalosporins or respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin) 3
Additional Interventions
- Consider intravenous methylxanthines (aminophylline 0.5 mg/kg/hour) by continuous infusion if patient is not responding to current therapy 3
- If methylxanthines are used, monitor blood levels daily 3, 2
- Administer diuretics if there is peripheral edema and raised jugular venous pressure 3
- Consider prophylactic subcutaneous heparin for prevention of thromboembolism 3
Ventilatory Support Assessment
- Consider non-invasive ventilation (NIV) if respiratory acidosis persists (pH < 7.26) despite standard medical management 3
- NIV has been shown to reduce the need for intubation and length of hospital stay 3
- Patients with confusion or large volume of secretions are less likely to respond well to NIV 3
Common Pitfalls to Avoid
- Avoid uncontrolled high-flow oxygen which may worsen hypercapnia 2
- Do not continue corticosteroids beyond 14 days unless specifically indicated 2
- Avoid prolonged courses of antibiotics beyond 7 days 2
- Do not use chest physiotherapy routinely as it is not recommended in acute COPD exacerbations 3