What is the treatment approach for a patient with a chronic obstructive pulmonary disease (COPD) exacerbation?

COPD Exacerbation Order Set for Hospitalized Patients

For hospitalized patients with COPD exacerbation, immediately initiate combined short-acting bronchodilators, systemic corticosteroids for exactly 5 days, controlled oxygen targeting 88-92%, and antibiotics when indicated by cardinal symptoms. 1

Initial Assessment Orders

Vital Signs and Monitoring

• Continuous pulse oximetry with target SpO2 88-92% 1
• Arterial blood gas within 1 hour of oxygen initiation (mandatory to assess for hypercapnia and acidosis) 1
• Vital signs every 4 hours initially 2
• Cardiac monitoring if arrhythmia suspected 2

Laboratory Studies

• Complete blood count with differential (assess eosinophil count if available - ≥2% predicts better corticosteroid response) 3
• Basic metabolic panel (monitor for hyperglycemia from steroids) 3
• Brain natriuretic peptide if heart failure suspected 2
• Sputum culture if purulent sputum present 2

Imaging

• Chest X-ray to exclude pneumonia, pneumothorax, or heart failure 2

Oxygen Therapy Orders

Controlled Oxygen Delivery

• Start with 28% Venturi mask or 2 L/min nasal cannula 4
• Target SpO2 88-92% (NOT 90-93% as in other conditions) 1
• Recheck ABG within 1 hour to ensure no worsening hypercapnia or acidosis 1
• Adjust FiO2 to maintain PaO2 ≥60 mmHg (8 kPa) without causing CO2 retention 2

Bronchodilator Orders

Nebulized Therapy (Preferred for Hospitalized Patients)

• Albuterol 2.5-5 mg PLUS ipratropium 0.25-0.5 mg via nebulizer every 4-6 hours 1
• Continue regular dosing (not PRN) during acute phase for first 24-48 hours 1
• May space to every 6 hours once clinical improvement occurs 2

Alternative: MDI with Spacer

• Albuterol 2 puffs (180 mcg) PLUS ipratropium 2 puffs (36 mcg) every 4-6 hours 2
• Note: Nebulizers preferred in sicker patients as they avoid need for 20+ coordinated inhalations 1

DO NOT ORDER:

• Theophylline or aminophylline (no added benefit, increased side effects) 2, 4

Systemic Corticosteroid Orders

Standard Regimen

• Prednisone 40 mg PO once daily for EXACTLY 5 days 1, 4, 3
• Alternative: Prednisolone 30-40 mg PO once daily for 5 days 2, 1
• Do NOT extend beyond 5-7 days (no additional benefit, increased adverse effects) 1, 3

If Patient Cannot Take Oral Medications

• Methylprednisolone 40 mg IV once daily 1, 3
• Alternative: Hydrocortisone 100 mg IV every 6-8 hours 2, 3
• Switch to oral as soon as patient can tolerate 3

Critical Point: Oral route equally effective to IV and preferred when possible 2, 3

Antibiotic Orders (When Indicated)

Indications for Antibiotics 1, 4

• Presence of 2 or more cardinal symptoms:
  • Increased sputum purulence (most important)
  • Increased dyspnea
  • Increased sputum volume

First-Line Antibiotic Choices (5-7 days) 2, 1

• Amoxicillin-clavulanate 875/125 mg PO twice daily, OR
• Azithromycin 500 mg PO day 1, then 250 mg daily days 2-5, OR
• Doxycycline 100 mg PO twice daily

For Treatment Failure or Risk Factors for Pseudomonas 2

• Levofloxacin 750 mg PO/IV once daily, OR
• Moxifloxacin 400 mg PO/IV once daily

Respiratory Support Orders

Noninvasive Ventilation (NIV) - First-Line for Respiratory Failure 2, 4

Indications for NIV:

• Acute hypercapnic respiratory failure (pH <7.35 with PaCO2 >45 mmHg) 1
• Persistent hypoxemia despite oxygen 1
• Severe dyspnea with respiratory muscle fatigue 1
• Respiratory rate >25 breaths/minute 2

NIV Settings (Initial):

• BiPAP mode: IPAP 10-12 cm H2O, EPAP 4-5 cm H2O 1
• Titrate IPAP to achieve tidal volume 6-8 mL/kg and patient comfort 1
• FiO2 to maintain SpO2 88-92% 1

Contraindications to NIV:

• Altered mental status/inability to protect airway 1
• Hemodynamic instability 2
• Recent facial/upper airway surgery 2
• Copious secretions patient cannot clear 1

Supportive Care Orders

Venous Thromboembolism Prophylaxis

• Enoxaparin 40 mg subcutaneous once daily (if CrCl >30) 1
• Alternative: Heparin 5000 units subcutaneous every 8-12 hours 1

Fluid Management

• Monitor fluid balance carefully 2
• Diuretics ONLY if peripheral edema AND elevated JVP present 1
• Avoid overhydration (worsens respiratory status) 2

Nutrition

• Regular diet as tolerated 2
• Nutritional consultation if malnourished 2

DO NOT ORDER:

• Chest physiotherapy (no evidence of benefit in acute exacerbations) 1

Discharge Planning Orders (Initiate on Day 1)

Before Discharge, Patient Must Have:

• Long-acting bronchodilator therapy initiated (LAMA, LABA, or combination) 2, 4
• Inhaler technique verified and documented 1
• Pulmonary rehabilitation referral scheduled within 3 weeks of discharge 1
• Follow-up appointment within 3-7 days 1
• Smoking cessation counseling if current smoker 1

Discharge Medications to Prescribe:

• Continue or initiate triple therapy (LAMA/LABA/ICS) if ≥2 exacerbations per year 1
• Albuterol MDI 2 puffs every 4-6 hours PRN for rescue 1
• Do NOT continue systemic corticosteroids beyond 5-7 days 3

Common Pitfalls to Avoid

Critical Errors:

• Extending corticosteroids beyond 5-7 days (increases adverse effects without benefit) 1, 3
• Using high-flow oxygen without monitoring ABG (risk of CO2 retention) 1
• Delaying NIV in patients with respiratory failure (increases intubation risk and mortality) 1
• Prescribing antibiotics without cardinal symptoms present (unnecessary exposure) 1
• Using theophylline (no benefit, significant side effects) 2, 4
• Defaulting to IV corticosteroids when oral route available (increased costs and adverse effects without improved outcomes) 3

Documentation Requirements:

• Document number of cardinal symptoms present (determines antibiotic indication) 1
• Document baseline functional status and degree of worsening 1
• Document exacerbation frequency over past year (determines discharge therapy) 1
• Document smoking status and cessation counseling provided 1