What are the treatment orders for a patient experiencing a chronic obstructive pulmonary disease (COPD) exacerbation?

COPD Exacerbation Treatment Orders

Immediately initiate short-acting β2-agonists (albuterol 2.5-5 mg) combined with ipratropium (0.25-0.5 mg) via nebulizer every 4-6 hours, start prednisone 30-40 mg orally once daily for exactly 5 days, provide controlled oxygen targeting SpO2 88-92%, and prescribe antibiotics for 5-7 days if the patient has increased sputum purulence plus either increased dyspnea or increased sputum volume. 1, 2

Immediate Assessment & Monitoring

• Obtain arterial blood gas within 1 hour of initiating oxygen therapy to assess for hypercapnia (PaCO2), hypoxemia (PaO2), and acidosis (pH <7.26), particularly in severe exacerbations 1, 2, 3
• Perform pulse oximetry continuously and target SpO2 88-92% to prevent tissue hypoxia while avoiding CO2 retention 1, 2, 3
• Order chest radiograph to exclude pneumonia, pneumothorax, or pulmonary edema, as this changes management in 7-21% of cases 2
• Obtain ECG if heart rate <60 or >110 bpm, or if cardiac symptoms present 2
• Complete blood count, electrolytes, and renal function within 24 hours 3

Bronchodilator Therapy

• Administer albuterol 2.5-5 mg plus ipratropium 0.25-0.5 mg via nebulizer every 4-6 hours during the acute phase (first 24-48 hours), as this combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 1, 2
• Nebulizers are preferred over metered-dose inhalers in hospitalized patients because they are easier to use and don't require coordination of 20+ inhalations 1, 2
• If using nebulizers in patients with hypercapnia, ensure they are driven by compressed air rather than oxygen 3
• Continue current long-acting bronchodilators (LAMA/LABA/ICS) unchanged during the exacerbation—do not escalate or modify maintenance therapy acutely 2

Systemic Corticosteroids

• Prescribe prednisone 30-40 mg orally once daily for exactly 5 days starting immediately, as this improves lung function, oxygenation, shortens recovery time, and reduces treatment failure by over 50% 1, 2
• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake 1, 2
• Do not extend corticosteroids beyond 5-7 days for a single exacerbation, as longer durations increase adverse effects without improving outcomes 1, 2
• For severe hospitalized patients requiring IV therapy, use methylprednisolone 30-40 mg IV daily, then transition to oral when appropriate 3

Antibiotic Therapy

• Prescribe antibiotics for 5-7 days if the patient has increased sputum purulence PLUS either increased dyspnea OR increased sputum volume (at least 2 of 3 cardinal symptoms with purulence being one) 1, 2
• First-line options: amoxicillin, doxycycline, or azithromycin based on local resistance patterns 1, 2
• Alternative options for severe exacerbations or risk factors for resistant organisms: amoxicillin/clavulanate, respiratory fluoroquinolones, or newer cephalosporins 1, 2, 3
• Target common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2

Oxygen Therapy

• Target SpO2 88-92% using controlled oxygen delivery (venturi mask preferred) to prevent tissue hypoxia while minimizing CO2 retention risk 1, 2, 3
• Repeat arterial blood gas within 60 minutes of starting oxygen and whenever clinical status deteriorates to assess for worsening hypercapnia or acidosis 2, 3
• Prevention of tissue hypoxia takes precedence over CO2 retention concerns 1

Respiratory Support for Severe Exacerbations

• Initiate noninvasive ventilation (NIV) immediately as first-line therapy for patients with acute hypercapnic respiratory failure (pH <7.26), persistent hypoxemia despite oxygen, or severe dyspnea with respiratory muscle fatigue 1, 2
• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by 65%, shortens hospitalization duration, and improves survival 1, 2
• Contraindications to NIV: confusion, large volume of secretions, inability to protect airway, hemodynamic instability 2, 3
• Consider invasive mechanical ventilation if NIV fails, particularly in patients with first episode of respiratory failure, demonstrable remedial cause, or acceptable baseline quality of life 2

Additional Interventions

• Avoid methylxanthines (theophylline/aminophylline) as first-line therapy due to increased side effects without added benefit 1, 2, 3
• Consider aminophylline 0.5 mg/kg/hour IV continuous infusion ONLY if patient is not responding to first-line bronchodilators, with daily blood level monitoring 3
• Administer diuretics ONLY if there is peripheral edema AND raised jugular venous pressure 1, 3
• Provide prophylactic subcutaneous heparin for venous thromboembolism prevention in patients with acute-on-chronic respiratory failure 2, 3
• Do not use chest physiotherapy in acute COPD exacerbations—there is no evidence of benefit 1, 3

Hospitalization Criteria

Admit patients with any of the following 1, 2:

• Marked increase in dyspnea intensity (severe dyspnea)
• Severe underlying COPD or failure to respond to initial outpatient management
• New physical signs (cyanosis, peripheral edema, confusion)
• Significant comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes, renal/liver failure)
• Inability to care for self at home or inadequate home support

ICU Admission Criteria

Transfer to ICU for 1:

• Impending or actual respiratory failure (pH <7.26 despite NIV)
• Hemodynamic instability
• Other end-organ dysfunction (shock, renal, liver, or neurological disturbance)

Discharge Planning & Follow-Up

• Schedule pulmonary rehabilitation within 3 weeks after discharge (NOT during hospitalization, as this increases mortality), as early post-discharge rehabilitation reduces hospital readmissions and improves quality of life 1, 2
• Ensure long-acting bronchodilators (LAMA/LABA or triple therapy) are initiated or optimized before discharge 2
• Provide intensive smoking cessation counseling with nicotine replacement therapy and behavioral intervention for current smokers 2
• Review and correct inhaler technique at discharge 2
• Schedule follow-up within 3-7 days to assess response to treatment 1, 2
• For patients with ≥2 moderate-to-severe exacerbations per year despite optimal triple therapy, consider adding long-term macrolide therapy (azithromycin 250-500 mg three times weekly) after assessing for QT prolongation risk 2, 4

Common Pitfalls to Avoid

• Never use uncontrolled high-flow oxygen—this worsens hypercapnia and increases mortality 2, 3
• Never continue corticosteroids beyond 5-7 days for a single exacerbation unless there is a separate indication 1, 2
• Never delay NIV in patients with acute hypercapnic respiratory failure and pH <7.26 2
• Never add a second LAMA to patients already on triple therapy (which contains glycopyrrolate)—there is no evidence supporting dual LAMA therapy 2
• Never start pulmonary rehabilitation during hospitalization—wait until post-discharge to reduce mortality risk 1, 2