What is the assessment and treatment plan for an older patient with a history of smoking, presenting with a COPD (Chronic Obstructive Pulmonary Disease) exacerbation, likely with co-morbidities such as hypertension, diabetes, or cardiovascular disease?

COPD Exacerbation Assessment and Plan Template

Assessment

Severity Determination

Immediately assess severity to determine disposition—loss of alertness, severe dyspnea, or significant clinical deterioration mandates hospital evaluation. 1

• Vital signs and oxygenation: Perform pulse oximetry immediately on all patients; obtain arterial blood gases if SpO2 <90% or respiratory acidosis suspected 1
• Mental status: Loss of alertness indicates severe exacerbation requiring immediate hospital admission 2, 1
• Respiratory distress: Assess respiratory rate, use of accessory muscles, ability to speak in full sentences 1
• Arterial blood gas interpretation: pH <7.35 indicates respiratory acidosis and severe exacerbation; pH <7.26 predicts poor outcome and may require non-invasive ventilation 1, 3
• Cardiac assessment: Perform ECG if heart rate <60 or >110 bpm, or if cardiac symptoms present; assess for cor pulmonale, congestive heart failure, and arrhythmias 1, 3
• Chest radiograph: Obtain on all patients to exclude pneumonia, pneumothorax, pulmonary edema, or lung cancer—changes management in 7-21% of cases 1

Identify Triggers and Complications

• Infection assessment: Purulent sputum suggests bacterial infection (most common: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) 2
• Alternative diagnoses: Consider pneumonia, pulmonary embolism, heart failure, pneumothorax, and acute coronary syndrome 1, 3
• Comorbidities: Evaluate for hypertension, diabetes, cardiovascular disease—these increase mortality risk and require specific management 3, 4

Risk Stratification for Disposition

Mild exacerbation (home management): Alert patient, no respiratory acidosis, SpO2 ≥90% on room air or low-flow oxygen, adequate social support 2, 1

Severe exacerbation (hospital admission): Any of the following: impaired consciousness, severe dyspnea at rest, respiratory acidosis (pH <7.35), inability to maintain SpO2 88-92% on low-flow oxygen, significant comorbid cardiac disease, hemoptysis, poor social support 2, 1, 3

ICU admission: pH <7.26, impending respiratory failure, hemodynamic instability, reduced ejection fraction with elevated pulmonary pressures 1, 3

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Plan

Immediate Management (All Settings)

Oxygen Therapy

Titrate oxygen to SpO2 88-92% using controlled delivery (Venturi mask ≤28% FiO2 or nasal cannula 2 L/min initially)—high-flow oxygen worsens hypercapnic respiratory failure and increases mortality. 1, 3

• Recheck arterial blood gases within 60 minutes of initiating oxygen and after any FiO2 changes 3
• Target PaO2 ≥6.6 kPa (≥50 mmHg) or SpO2 ≥90% without causing pH to fall below 7.26 3
• If pH remains stable, titrate oxygen upward to achieve PaO2 >7.5 kPa (>56 mmHg) 3

Bronchodilator Therapy

Administer nebulized β2-agonists (albuterol 2.5-5 mg) and anticholinergics (ipratropium 0.25-0.5 mg) immediately—combination therapy provides optimal bronchodilation. 2, 1, 3

• Use compressed air to drive nebulizers if patient is hypercapnic or acidotic 3
• Continue nebulized bronchodilators for 24-48 hours until clinical improvement 1
• Transition to usual inhaler therapy (MDI with spacer or dry powder inhaler) 24-48 hours before discharge 1
• During acute exacerbations, breathless patients may find nebulizers easier to use than inhalers 2

Pharmacological Management

Systemic Corticosteroids

Administer oral prednisolone 30 mg daily for 7-14 days for all hospitalized patients and severe outpatient exacerbations—oral route is preferred over intravenous. 1

• No advantage to intravenous over oral corticosteroids without clear indication 1
• Systemic corticosteroids reduce exacerbation duration and improve outcomes 1

Antibiotics

Prescribe antibiotics for 7-14 days when sputum becomes purulent, indicating bacterial infection. 2

• First-line options: Amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid 2
• Alternative treatments: Newer cephalosporins, macrolides, or quinolone antibiotics 2
• Culture sputum if response to initial therapy is poor—increasing resistance patterns of Staphylococcus, Haemophilus, and Streptococcus 2
• No advantage to prophylactic or aerosolized antibiotic therapy except in selected patients with frequently recurring infections 2

Respiratory Support

Non-Invasive Ventilation (NIV)

Initiate NIV for patients with acute or acute-on-chronic respiratory failure, particularly when pH <7.35 despite initial therapy—this is a strong recommendation with high-quality evidence. 1

• NIV reduces mortality and intubation rates in COPD exacerbations with respiratory acidosis 1
• pH <7.26 predicts poor outcome and strongly indicates need for NIV 3
• Patients with COPD should be extubated to NIV 5

Hospital-Specific Management

Monitoring Requirements

• Serial arterial blood gases if initially acidotic or hypercapnic 3
• Continuous pulse oximetry for trending 3
• Full blood count, urea and electrolytes, ECG within first 24 hours 3
• Serial peak flow measurements 3

Cardiac Comorbidity Management

For patients with congestive heart failure or cor pulmonale, avoid aggressive fluid administration and monitor for peripheral edema—oxygen therapy reduces pulmonary vascular resistance and may improve right ventricular function. 3

Discharge Planning and Prevention

Pre-Discharge Assessment

• Measure FEV1 before discharge to establish new baseline 1
• Check arterial blood gases on room air before discharge in patients who presented with respiratory failure 1
• Ensure patient can maintain SpO2 88-92% on room air or prescribed home oxygen 1

Pulmonary Rehabilitation

Initiate pulmonary rehabilitation within 3 weeks after hospital discharge—do not start during hospitalization. 1

• Starting rehabilitation during hospitalization is not recommended 1
• Post-discharge rehabilitation reduces readmissions and improves outcomes 1

Smoking Cessation

Provide smoking cessation counseling at every encounter—this is the single most important intervention to prevent future exacerbations and slow disease progression. 2

• Simple advice results in cessation in a minority of patients 2
• Nicotine replacement (gum or transdermal) and behavioral intervention increase success rates 2
• Repeated attempts are often needed; support patients through multiple cycles 2

Long-Term Pharmacotherapy

• Continue or optimize inhaled bronchodilators (long-acting β2-agonists and/or long-acting anticholinergics) 1
• Consider triple therapy (LABA + LAMA + inhaled corticosteroid) for patients with continuing exacerbations, especially if blood eosinophils elevated 6
• For severe COPD with chronic bronchitis and recurrent exacerbations despite optimal therapy, consider roflumilast 500 mcg daily (reduces exacerbation rate by 15-18%) 7

Vaccination

• Administer influenza and pneumococcal vaccination 8

Common Pitfalls to Avoid

• Do not delay hospital evaluation if severity is uncertain—assessment should occur in hospital setting 2, 1
• Avoid sedatives—these worsen respiratory depression 1
• Do not use high-flow oxygen without monitoring—worsens hypercapnia and increases mortality 1
• Do not prescribe antibiotics without evidence of bacterial infection (purulent sputum) 2
• Do not start pulmonary rehabilitation during hospitalization—wait until post-discharge 1