What should be included in a discharge plan for an adult patient with a history of smoking and possible comorbidities, experiencing a chronic obstructive pulmonary disease (COPD) exacerbation?

Discharge Plan for COPD Exacerbation

A comprehensive discharge plan for COPD exacerbation must include optimization of maintenance therapy, smoking cessation counseling, pulmonary rehabilitation referral, patient education on inhaler technique, and early follow-up within 30 days to reduce readmissions and improve outcomes. 1, 2

Pre-Discharge Clinical Assessment

Before discharge, complete the following assessments to ensure clinical stability and guide ongoing management:

• Record FEV1 measurement to establish baseline post-exacerbation lung function 1
• Check arterial blood gases on room air in patients who presented with hypercapnic respiratory failure or low PaO2 on admission, as this guides assessment for long-term oxygen therapy (LTOT) 1, 3
• Transition from nebulized bronchodilators to usual inhaler at least 24-48 hours before discharge to confirm patient can manage their device independently 1, 3
• Ensure clinical stability with less dyspnea, improved peak flow, and improved oxygen saturation before discharge 1

Medication Optimization at Discharge

Bronchodilator Therapy

• Prescribe or optimize long-acting bronchodilators (LABA and/or LAMA) as maintenance therapy, as these reduce future exacerbation risk 4
• For patients with history of exacerbations, prescribe combination ICS/LABA (such as fluticasone/salmeterol 250/50 mcg twice daily), which reduces exacerbation rates by 30% compared to LABA alone 4
• Provide short-acting bronchodilator (albuterol or salbutamol) for rescue use, with clear instructions that maintenance inhalers are not for acute symptom relief 4

Corticosteroids and Antibiotics

• Stop oral corticosteroids abruptly after 7 days unless there are specific reasons for long-term use; do not continue beyond the acute treatment period 1, 3
• Antibiotics typically do not need continuation beyond 7 days after discharge 1, 3

Home Oxygen Assessment

• Assess for LTOT if PaO2 ≤7.3 kPa (55 mmHg) or SaO2 ≤88% on room air despite optimal therapy, confirmed twice over 3 weeks 3
• LTOT should be prescribed for at least 15 hours/day to improve survival in patients with chronic respiratory failure 3

Patient and Caregiver Education

Inhaler Technique

• Verify patient (or carer) understands the treatment prescribed and can demonstrate proper use of all delivery devices before discharge 1
• Provide hands-on training with each inhaler device, as improper technique is a common cause of treatment failure 1, 5
• Have patient rinse mouth with water after ICS use to reduce risk of oropharyngeal candidiasis 4

Self-Management and Action Plans

• Provide written action plan that includes instructions on recognizing early signs of exacerbation (increased breathlessness, increased sputum volume, purulent sputum) and when to initiate treatment or seek medical attention 1, 6
• Prescribe "rescue pack" of antibiotics and oral corticosteroids for home use if appropriate, with clear instructions on when to start treatment 6, 5

Smoking Cessation

• Counsel all current smokers on smoking cessation and offer pharmacotherapy (nicotine replacement, varenicline, or bupropion) plus behavioral support 1, 2
• Assess environmental exposures including secondhand smoke, occupational exposures, and indoor air pollution 2

Pulmonary Rehabilitation Referral

• Refer all patients to pulmonary rehabilitation program to begin within 4 weeks of discharge, as this improves exercise capacity and quality of life with benefits evident at 6 months 1, 2
• Pulmonary rehabilitation initiated after exacerbation has demonstrated significant improvements in functional outcomes 1

Follow-Up Care and Continuity

Outpatient Appointments

• Schedule follow-up within 30 days of discharge (ideally within 2 weeks) to reduce exacerbation-related readmissions 7, 2, 8
• Refer to pulmonology outpatient clinic if patient is not already established with a pulmonologist 5
• Inform the patient's GP within 48 hours of discharge with complete discharge summary including medications, follow-up plans, and any pending investigations 1

Post-Discharge Monitoring

• Follow-up visit should include review of medication adherence, reassessment of inhaler technique, evaluation for need for LTOT reassessment, and screening for comorbidities 1, 5
• Consider chest radiograph at follow-up if patient fails to respond fully to treatment 1

Social Support Assessment

• Ensure adequate home support to enable patient to cope at home, including assessment of living situation (alone/with support/with family) and suitability of accommodation 1
• Arrange home care services if needed, including district nursing, home oxygen delivery, or social services support 1

Vaccination

• Administer or schedule pneumococcal vaccine if not previously given 9, 2
• Ensure annual influenza vaccination is up to date 2

Medication Supply

• Provide sufficient medication to last until the next opportunity for consultation with the GP or specialist, typically a 30-day supply 1
• Include written prescriptions for all maintenance medications with clear dosing instructions 1

Common Pitfalls to Avoid

• Do not discharge patients on nebulized therapy without confirming they can manage with standard inhalers, as this indicates inadequate recovery 1, 3
• Do not continue oral corticosteroids indefinitely without specific indication, as this increases adverse effects without proven benefit 1
• Do not discharge without confirming adequate social support, as this is a major risk factor for readmission 1
• Do not delay pulmonary rehabilitation referral, as early initiation (within 4 weeks) provides maximum benefit 1, 2