Discharge Management for COPD Exacerbation with MDI Salbutamol
Discharge the patient on salbutamol MDI with spacer at 2 puffs (200 mcg) every 2-4 hours as needed, ensuring they have been stable on this regimen for at least 24-48 hours before leaving the hospital. 1, 2
Bronchodilator Transition and Dosing
- Switch from nebulizer to MDI with spacer at least 24-48 hours before discharge to confirm clinical stability on the discharge regimen 3, 2
- Prescribe salbutamol (albuterol) MDI at 2 puffs (90-100 mcg per puff) every 2-4 hours as needed for symptom relief 3, 1
- Consider adding ipratropium bromide MDI if the patient had severe symptoms during hospitalization or demonstrated poor response to beta-agonist alone, though combination therapy may not provide additional benefit in all patients 3, 4
- MDI with spacer is equally effective as nebulized therapy once the patient is stabilized and facilitates earlier discharge 1, 5
Mandatory Pre-Discharge Requirements
Verify and document proper MDI technique before the patient leaves—this is non-negotiable as incorrect technique is a major cause of treatment failure 1, 2
- The patient must demonstrate correct spacer use, including: slow deep inhalation, 5-second breath hold, and waiting 30-60 seconds between puffs 2
- Record FEV1 before discharge to establish a baseline for future comparison 3
- Check arterial blood gases on room air if the patient presented with hypercapnic respiratory failure or significant hypoxemia, as this guides need for long-term oxygen therapy assessment 3, 2
Corticosteroid Management
- Complete a 10-14 day course of oral prednisone 30-40 mg daily if systemic corticosteroids were initiated during hospitalization 3, 1
- Corticosteroids can be stopped abruptly after 7-14 days unless there are specific indications for long-term use 3
- Consider adding inhaled corticosteroids by MDI for patients with frequent exacerbations, though this should be assessed separately from acute management 1
Antibiotic Completion
- Ensure the patient completes a 5-7 day course of antibiotics if started for purulent sputum or increased sputum volume 1
- Antibiotics typically do not need to continue beyond 7 days 3
Critical Discharge Checklist
Clinical stability criteria that must be met:
- Patient has been stable on discharge medications (MDI regimen) for minimum 24 hours 2
- Less dyspnea, improved oxygen saturation, and better peak expiratory flow 3
- For patients with clear or scattered rhonchi, this represents adequate clinical improvement to proceed with discharge 3
Follow-up arrangements:
- Schedule follow-up within 30 days of discharge to reduce readmission risk 1
- Reassess oxygen requirements 4-6 weeks post-discharge if oxygen was initiated during hospitalization 2, 6
Common Pitfalls to Avoid
- Do not discharge before 24 hours of stability on MDI therapy—this significantly increases relapse and readmission risk 2
- Do not continue nebulizers at home unless there is a specific documented indication; MDI with spacer is equally effective and more practical 1, 5
- Do not skip the inhaler technique verification—poor technique is a leading preventable cause of treatment failure 1, 2
- Do not continue oxygen therapy without physiological reassessment if it was started during the acute phase, as many patients will no longer meet criteria once stabilized 3, 2