What is the recommended discharge plan for patients with chronic obstructive pulmonary disease (COPD) exacerbations?

Discharge Plan for COPD Exacerbations

For patients hospitalized with a COPD exacerbation, initiate pulmonary rehabilitation within 3 weeks after discharge, ensure completion of oral corticosteroids (30 mg prednisolone for 7-14 days total), optimize bronchodilator therapy with MDI/spacer technique verification, complete antibiotics if indicated, and schedule early follow-up within 30 days. 1

Pulmonary Rehabilitation Timing

Do not initiate pulmonary rehabilitation during hospitalization as this increases mortality, despite improving exercise capacity. 1 The ERS/ATS guidelines provide a conditional recommendation against in-hospital pulmonary rehabilitation based on evidence showing increased mortality (23.8% versus 15.6%; RR 1.54). 1

Initiate pulmonary rehabilitation within 3 weeks of hospital discharge to reduce hospital readmissions (21.5% versus 46.8%; RR 0.37) and improve quality of life (mean difference −11.75 points). 1 When started within 8 weeks, pulmonary rehabilitation increases exercise capacity by a mean of 57.47 meters. 1

Medication Optimization at Discharge

Corticosteroids

• Complete a 7-14 day course of oral prednisolone 30 mg daily unless specific contraindications exist. 1, 2 This should be prescribed to all hospitalized patients with COPD exacerbations. 1
• Do not continue corticosteroids long-term after the acute course. 1

Bronchodilator Therapy

• Transition to MDI with spacer as the primary delivery method rather than continuing nebulizers, as MDI with spacer is equally effective once stabilized and facilitates discharge. 2
• Prescribe short-acting beta-agonist (SABA) 2 puffs every 2-4 hours as needed for rescue therapy. 2
• Add ipratropium bromide MDI for patients with more severe symptoms or poor response to beta-agonist alone during hospitalization. 2
• Verify proper MDI technique by having the patient demonstrate correct use before discharge. 2
• Ensure transition from nebulizer to MDI occurs at least 24 hours prior to discharge to confirm stability on the discharge regimen. 2

Antibiotic Completion

• Ensure completion of 5-7 day antibiotic course if started during treatment for patients with two or more cardinal symptoms (increased breathlessness, increased sputum volume, purulent sputum). 1, 2
• Common antibiotics (amoxicillin, tetracycline, or amoxicillin/clavulanate) are usually sufficient unless there was poor response. 1, 2

Discharge Readiness Criteria

Before discharge, ensure:

• Adequate home support for the patient to cope independently. 1
• Patient or carer understands all prescribed treatments and delivery device techniques. 1
• Sufficient medication supply to last until the next GP consultation. 1
• Oxygen saturation maintained at 88-92% if supplemental oxygen required, to avoid worsening hypercapnia. 3

Follow-Up Planning

• Schedule follow-up within 30 days of discharge to reduce exacerbation-related readmissions. 3, 2
• Inform the patient's GP within 48 hours if discharged from emergency department. 1
• Use follow-up visit to address smoking cessation, lifestyle modifications, activity levels, weight management, and medication review. 1

Long-Term Maintenance Considerations

For patients with frequent exacerbations (>1 per year despite optimal therapy):

• Consider LAMA/LABA combination as initial bronchodilator strategy to maximize bronchodilation. 4
• For patients with asthma-COPD overlap or high blood eosinophil counts, consider adding inhaled corticosteroids to LABA/LAMA. 4
• For chronic bronchitis phenotype, consider PDE-4 inhibitor (roflumilast) or high-dose mucolytic agents. 4
• For frequent bacterial exacerbations or bronchiectasis, consider mucolytic agents or macrolide antibiotic (azithromycin). 4

Common Pitfalls to Avoid

• Do not start pulmonary rehabilitation during hospitalization as this paradoxically increases mortality despite functional improvements. 1
• Do not delay pulmonary rehabilitation referral beyond 3 weeks as this is the optimal window for reducing readmissions and improving quality of life. 1
• Do not discharge patients still requiring nebulizers without first transitioning to MDI/spacer and confirming stability for at least 24 hours. 2
• Do not over-oxygenate - target saturation 88-92% to prevent worsening hypercapnia. 3
• Do not discharge without verifying inhaler technique as poor technique is a common cause of treatment failure. 2