Home Instructions for COPD Patients After Hospital Discharge
COPD patients discharged after hospitalization should receive a comprehensive treatment package including antibiotics, oral corticosteroids, nebulized bronchodilators (transitioned to MDI with spacer before discharge), oxygen if needed, and must be enrolled in pulmonary rehabilitation within 3 weeks of discharge—not during hospitalization—to reduce readmissions and mortality. 1, 2
Patient Selection and Safety Assessment
Before discharge, confirm the patient is safe for home management by ensuring: 1
- Absence of exclusion criteria: No impaired consciousness, confusion, acidosis (pH >7.35), serious co-morbidity, or inadequate social support 1
- Adequate home support: Patient or caregiver can manage essential activities of daily living with help from relatives, social services, or respiratory liaison nurses 1
- Ability to access emergency help: Patient can rapidly obtain assistance if condition deteriorates 1
- Oxygen saturation maintained at 88-92% if supplemental oxygen required, to avoid worsening hypercapnia 2, 3
Medication Instructions at Discharge
Bronchodilators
Transition from nebulizers to MDI with spacer at least 24-48 hours before discharge once clinically stable, as MDI with spacer is equally effective and facilitates home management 2, 3. The British Thoracic Society emphasizes this transition is critical—patients should not be discharged still requiring nebulizers. 2
- Short-acting beta-agonist: 2 puffs every 2-4 hours as needed for rescue therapy 2
- Ipratropium bromide MDI: Add for patients with more severe symptoms 2
- Verify proper MDI technique: Have the patient demonstrate correct use before discharge—this is a common cause of treatment failure if skipped 2, 4, 5
Corticosteroids
Complete a 7-14 day course of oral prednisolone 30 mg daily unless specific contraindications exist 2, 3. The British Thoracic Society recommends stopping oral corticosteroids abruptly after 7 days unless there are specific reasons for long-term use—do not continue long-term after the acute course. 2, 3
Antibiotics
Complete the prescribed antibiotic course (typically 5-7 days), chosen based on local resistance patterns 3. Antibiotics typically do not need continuation beyond 7 days. 3
Oxygen Therapy
If oxygen is required, provide clear instructions: 1
- Target saturation: 88-92% to prevent worsening hypercapnia 2, 3
- Assess for long-term oxygen therapy (LTOT) criteria before discharge if patient presented with hypercapnic respiratory failure 3
- LTOT indicated if PaO2 ≤7.3 kPa or SaO2 ≤88% on room air despite optimal therapy, confirmed twice over 3 weeks 3
Pulmonary Rehabilitation Timing
Critical timing recommendation from the European Respiratory Society and American Thoracic Society: 1, 2
Initiate pulmonary rehabilitation within 3 weeks after discharge (conditional recommendation, very low quality evidence) 1, 2
Do NOT initiate pulmonary rehabilitation during hospitalization (conditional recommendation, very low quality evidence) 1, 2
Home Care Delivery Model
Early supported discharge (ESD) is the preferred model over admission avoidance for most hospitals 1. Home care should be delivered by: 1
- Specialist respiratory nurses/physiotherapists or generic teams by district nurses 1
- Typical duration: 11 days median length of stay in ESD schemes 1
- Visits usually occur daily initially, with 3-11 visits total depending on patient needs 1
- Telephone contact via respiratory practitioner's mobile phone should be provided 1
- Leave copy of clinical notes with patient to assist GP if called in emergency 1
Patient Education Components
Provide written and verbal instructions covering: 1, 2
- Understanding the discharge plan: Patients should understand why early supported discharge was chosen, the meaning of supported discharge, and necessity of home visits by respiratory practitioners 1
- Medication regimen: All prescribed treatments and delivery device techniques must be understood by patient or caregiver 2
- Recognition of deterioration: When to step up treatment or seek emergency help 1
- Smoking cessation: Address at follow-up visit if applicable 2
- Lifestyle modifications: Activity levels, weight management 2
Follow-Up Planning
Schedule follow-up within 30 days of discharge to reduce exacerbation-related readmissions 2. The European Respiratory Society emphasizes this timing is critical. 2
- Inform patient's GP within 48 hours if discharged from emergency department 2
- Use follow-up visit to address: smoking cessation, lifestyle modifications, activity levels, weight management, and medication review 2
- Reclassify patient according to GOLD criteria and optimize pharmacological therapy 6
Discharge Readiness Checklist
Before discharge, confirm: 2
- Adequate home support for patient to cope independently 2
- Patient or carer understands all prescribed treatments and delivery device techniques 2
- Sufficient medication supply to last until next GP consultation 2
- Patient has demonstrated correct inhaler technique 2, 5
- Oxygen saturation maintained at 88-92% if supplemental oxygen required 2
- Patient stable on MDI/spacer for at least 24 hours (not requiring nebulizers) 2, 3
Critical Pitfalls to Avoid
Do not start pulmonary rehabilitation during hospitalization—this increases mortality despite functional improvements 1, 2. Wait until 3 weeks post-discharge. 1, 2
Do not delay pulmonary rehabilitation referral beyond 3 weeks—this is the optimal window for reducing readmissions and improving quality of life 2. The evidence shows clear benefit when started within this timeframe. 2
Do not discharge patients still requiring nebulizers without first transitioning to MDI/spacer and confirming stability for at least 24 hours 2, 3. This is a common error that leads to readmissions. 2
Do not over-oxygenate—target saturation 88-92% to prevent worsening hypercapnia 2, 3. Excessive oxygen therapy can worsen respiratory acidosis in COPD patients. 3
Do not discharge without verifying inhaler technique—poor technique is a common cause of treatment failure 2, 4, 5. Studies show inhaler errors start appearing immediately on Day 1 after training, with incorrect inspiratory flow rates being the most common mistake. 4
Do not continue corticosteroids long-term after the acute 7-14 day course unless specific indications exist 2, 3. Stop abruptly after completion. 3