Can you create an inpatient Epic dot phrase for an acute COPD exacerbation?

Inpatient Epic Dot Phrase for COPD Exacerbation

Assessment and Diagnosis

.COPDEXACERB

Chief Complaint: Acute exacerbation of COPD

HPI: Patient with known COPD presenting with acute worsening of respiratory symptoms. Cardinal symptoms present:

• Increased dyspnea
• Increased sputum volume
• Increased sputum purulence

Severity Classification: 1

• Mild (outpatient management with SABAs only)
• Moderate (requires SABAs + antibiotics/corticosteroids)
• Severe (requires hospitalization ± acute respiratory failure)

Triggers assessed:

• Recent respiratory infection
• Medication non-adherence
• Environmental exposures
• Smoking status: ___ pack-years

Exacerbation frequency past year: ___ episodes 2

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Initial Management

Oxygen Therapy: 2, 1

• Target SpO2: 88-92% using Venturi mask (24-28% FiO2) or nasal cannula (1-2 L/min)
• ABG obtained within 60 minutes of oxygen initiation
• Repeat ABG at 30-60 minutes if pH <7.35 or PaCO2 >45 mmHg

Bronchodilator Therapy: 2, 1

• Albuterol 2.5-5 mg + Ipratropium 0.25-0.5 mg via nebulizer q4-6h
• Nebulizers powered with compressed air (not oxygen) if hypercapnic
• Continue until clinical improvement (typically 24-48 hours)

Systemic Corticosteroids: 2, 1

• Prednisone 40 mg PO daily x 5 days (started immediately)
• Oral route preferred unless unable to tolerate PO
• Do NOT extend beyond 5-7 days without separate indication

Antibiotic Therapy (if indicated): 2, 1 Criteria: Increased sputum purulence PLUS (increased dyspnea OR increased sputum volume)

• Amoxicillin-clavulanate 875/125 mg PO BID x 5-7 days (first-line)
• Doxycycline 100 mg PO BID x 5-7 days (alternative)
• Azithromycin 500 mg day 1, then 250 mg daily x 4 days (alternative)

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Respiratory Support

NIV Indications: 2, 1 Initiate immediately if:

• pH <7.35 with PaCO2 >45 mmHg persisting >30 minutes after initial therapy
• Persistent hypoxemia despite oxygen
• Severe dyspnea with respiratory muscle fatigue

NIV Contraindications: 2

• Altered mental status/inability to protect airway
• Large volume secretions
• Hemodynamic instability
• Recent facial/upper airway surgery

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Monitoring

Vital Signs: q4h initially, then per nursing protocol ABG: Within 1 hour of oxygen initiation, repeat PRN based on clinical status 2 Chest X-ray: To exclude pneumonia, pneumothorax, pulmonary edema 2 ECG: If HR <60 or >110, or cardiac symptoms present 2 Labs: CBC, CMP (assess electrolytes, renal function, glucose) 2

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Discharge Planning

Maintenance Therapy: 2, 1

• Continue/optimize long-acting bronchodilators (LAMA/LABA/ICS) before discharge
• Do NOT step down from triple therapy during or immediately after exacerbation
• Verify inhaler technique at discharge

Pulmonary Rehabilitation: 2, 1

• Schedule within 3 weeks after discharge (NOT during hospitalization)
• Reduces readmissions and improves quality of life

Follow-up: 2

• Outpatient appointment within 3-7 days
• Smoking cessation counseling if applicable
• Review exacerbation prevention strategies

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Medications to AVOID

• Methylxanthines (theophylline/aminophylline): Increased side effects without benefit 2, 1
• Chest physiotherapy: No evidence of benefit in acute exacerbations 2
• High-flow oxygen (>28% FiO2) without ABG monitoring: Worsens hypercapnic respiratory failure 2

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Plan: Admit to [floor/ICU]. Continue above management. Reassess in 30-60 minutes for clinical response. 1, 2