What are the key components of a discharge plan for patients with asthma and Chronic Obstructive Pulmonary Disease (COPD)?

Discharge Planning for Asthma and COPD Patients

Patients with asthma or COPD should only be discharged when they have been clinically stable on discharge medications for at least 24 hours, with peak expiratory flow >75% of predicted or best value (for asthma), documented inhaler technique, a written self-management plan, and scheduled follow-up within one week. 1, 2

Clinical Stability Criteria Before Discharge

For Asthma Patients

• Peak expiratory flow (PEF) must be >75% of predicted or personal best value 1, 2
• PEF diurnal variability must be <25% 1, 2
• No nocturnal symptoms should be present 1, 2
• Respiratory rate <25 breaths/min and pulse <110 beats/min 1
• Patient must have been stable on discharge medications for 24 hours minimum 1, 3

For COPD Patients

• Clinical improvement demonstrated after nebulized bronchodilator treatment 1
• If oxygen was required, reassess need for long-term oxygen therapy (LTOT) before discharge 1
• Patients should be observed for 24-48 hours after switching from nebulizer to hand-held inhaler 1

Mandatory Medication Changes Before Discharge

Asthma Discharge Medications

• Prednisolone 30-60 mg daily for 1-3 weeks (or longer in chronic asthma cases) 1, 3
• Inhaled corticosteroids at a HIGHER dosage than before admission - this must be started at least 48 hours before discharge 1, 3
• Inhaled β-agonists for "as necessary" use 1
• Oral theophylline, long-acting β-agonists, or inhaled ipratropium if required 1

COPD Discharge Medications

• Short-acting β-agonist and/or ipratropium via MDI with spacer or hand-held nebulizer 1
• Prednisone 30-40 mg orally daily for 10-14 days 1
• Consider inhaled corticosteroids by MDI or hand-held nebulizer 1
• Antibiotics if sputum characteristics changed (purulence/volume) - choice based on local resistance patterns 1

Device Transition Requirements

• Nebulizers must be replaced by standard inhaler devices 24-48 hours before discharge unless home nebulizer is required 1, 3
• Inhaler technique must be checked and documented in the medical record 1, 2
• If oral theophyllines are prescribed, blood theophylline concentrations should be monitored 1

Essential Self-Management Tools

Peak Flow Meter and Education

• Every patient must receive their own peak flow meter before discharge 1, 2, 3
• Patients must be taught how to use the meter correctly 1, 2
• Training should include interpretation of results and appropriate actions 1, 2

Written Self-Management Plan (Non-Negotiable)

• A written action plan must specify exact PEF values at which to:
  • Increase treatment 1, 2, 3
  • Call their doctor 1, 2, 3
  • Return to hospital or emergency department 1, 2, 3

Follow-Up Arrangements (Mandatory)

Asthma Follow-Up Schedule

• Primary care physician visit within 1 week of discharge 1, 2, 3
• Respiratory physician appointment within 4 weeks 1, 2, 3

COPD Follow-Up Considerations

• Reassessment of oxygen requirements if started during hospitalization 1
• Consider pulmonary rehabilitation referral for patients recovering from exacerbation 1

Investigation of Admission Circumstances

Before discharge, systematically review:

• Was there an avoidable precipitating cause or allergen exposure? 1, 3
• Was the patient compliant with regular treatment, and if not, why not? 1, 3
• Did the patient or relatives react appropriately to worsening symptoms? 1, 3
• Was medical management before admission appropriate? 1, 3

Vaccination Considerations

Pneumococcal Vaccination

• All asthma patients should receive pneumococcal vaccination before discharge as asthma is a high-risk condition 4
• The 23-valent pneumococcal polysaccharide vaccine is recommended for adults with asthma at any age 4
• Immunocompromised patients should receive both 13-valent conjugate and 23-valent polysaccharide vaccines 4

Important Caveat

• Vaccination should not delay discharge if the patient meets other clinical stability criteria 4

Critical Pitfalls to Avoid

Medication Errors

• Discharging before 24 hours on medications significantly increases relapse risk 2, 3
• Failing to increase inhaled corticosteroid dose above pre-admission levels leads to treatment failure 2, 3
• Inadequate duration or dosing of systemic corticosteroids increases relapse risk 3

Documentation and Education Failures

• Not providing a written self-management plan is the single most preventable cause of readmission 2, 3
• Failing to check and document inhaler technique results in medication delivery failure 2, 3
• Not arranging follow-up creates dangerous gaps in care continuity 2, 3

Device-Related Issues

• Switching from nebulizer to MDI too close to discharge without adequate observation period 1
• Not considering alternative inhaler devices if technique is inadequate 1

COPD-Specific Pitfalls

• Continuing oxygen therapy without reassessing physiological need increases unnecessary costs without benefit 1
• Overuse of inhaled corticosteroids in COPD patients who don't meet criteria (frequent exacerbations, high eosinophils, or concomitant asthma) puts patients at risk for pneumonia without clear benefit 5