What is the recommended inpatient management plan, including intravenous medications, for an adult patient admitted with an acute exacerbation of chronic obstructive pulmonary disease?

Hospital Inpatient Management Plan for Acute COPD Exacerbation with IV Drugs

Immediate Assessment & Oxygen Therapy

Target oxygen saturation of 88–92% using controlled-delivery devices (Venturi mask 24–28% FiO₂ or nasal cannula 1–2 L/min) to correct hypoxemia while avoiding CO₂ retention. 1, 2

• Obtain arterial blood gas within 60 minutes of starting oxygen to identify hypercapnia (PaCO₂ > 45 mmHg) or acidosis (pH < 7.35) 1, 2
• Repeat ABG at 30–60 minutes if clinical deterioration occurs or if initial pH < 7.35 1, 2
• High-flow oxygen (>28% FiO₂ or >4 L/min) without blood-gas monitoring increases mortality by approximately 78% and should be avoided 1, 2
• Obtain chest radiograph on all hospitalized patients to exclude pneumonia, pneumothorax, or pulmonary edema, as imaging changes management in 7–21% of cases 2

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Bronchodilator Therapy

Administer combined nebulized albuterol 2.5–5 mg plus ipratropium 0.25–0.5 mg every 4–6 hours during the acute phase; this combination provides superior bronchodilation lasting 4–6 hours compared to either agent alone. 1, 2

• Power nebulizers with compressed air (not oxygen) when hypercapnia or respiratory acidosis is present; provide supplemental oxygen separately via nasal cannula 1, 2
• Continue nebulized treatments for 24–48 hours or until clinical improvement, then transition to metered-dose inhalers with spacer 1, 2
• Avoid intravenous methylxanthines (theophylline/aminophylline) as they increase adverse effects without clinical benefit 3, 1, 2

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Systemic Corticosteroid Protocol

Oral prednisone 30–40 mg once daily for exactly 5 days is the evidence-based standard; this short course is as effective as 14-day regimens while reducing cumulative steroid exposure by >50%. 1, 2

• Oral administration is preferred and equally effective to intravenous unless the patient cannot tolerate oral medications 1, 2
• If oral route is not possible: Use IV methylprednisolone 40 mg every 6–8 hours (equivalent to prednisone 30–40 mg daily) or IV hydrocortisone 100 mg every 6 hours 1, 4
• Alternative IV regimen: Methylprednisolone 125 mg IV once daily (FDA-labeled dose for acute conditions) 1
• For severe, life-threatening exacerbations requiring mechanical ventilation or ICU care: Consider methylprednisolone 0.5–2 mg/kg IV every 6 hours 1
• The 5-day course improves lung function, shortens recovery time, reduces treatment failure by >50%, and lowers 30-day rehospitalization risk 1, 2
• Do not extend systemic corticosteroids beyond 5–7 days unless another indication exists, as longer courses increase hyperglycemia (OR 2.79), pneumonia-related hospitalization, and mortality without additional benefit 3, 1, 2
• No taper is required after a 5-day course 1

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Antibiotic Therapy

Prescribe antibiotics for 5–7 days when sputum purulence is present together with either increased dyspnea OR increased sputum volume (two of three cardinal symptoms, with purulence required). 1, 2

• This strategy reduces short-term mortality by ~77%, treatment failure by ~53%, and sputum purulence by ~44% 1, 2
• First-line agents (selected per local resistance patterns): Amoxicillin-clavulanate 875/125 mg twice daily, doxycycline 100 mg twice daily, or azithromycin 500 mg day 1 then 250 mg daily for 4 days 1, 2
• Target common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2
• Antibiotics are also indicated when all three cardinal symptoms are present or when mechanical ventilation is required 1, 2

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Non-Invasive Ventilation (NIV)

Initiate NIV immediately as first-line therapy when acute hypercapnic respiratory failure (PaCO₂ > 45 mmHg) with acidosis (pH < 7.35) persists >30 minutes after standard medical treatment. 1, 2

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by ~50%, shortens hospital stay, and improves survival with success rates of 80–85% 1, 2, 5
• Transfer to ICU if pH remains <7.26 despite NIV 1, 2
• Contraindications to NIV: Altered mental status with inability to protect airway, large-volume secretions, hemodynamic instability, or recent facial/upper-airway surgery 1, 2, 5

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Additional Supportive Measures

• Diuretics: Use only if peripheral edema and elevated jugular venous pressure are present; avoid aggressive diuresis that could compromise cardiac output 1, 2
• Prophylactic subcutaneous heparin: Recommended for venous thromboembolism prevention in patients with acute-on-chronic respiratory failure 1, 2
• Avoid chest physiotherapy: No evidence of benefit in acute COPD exacerbations 1, 2
• Monitor for hyperglycemia during corticosteroid therapy and adjust antidiabetic medications accordingly 1

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Discharge Planning

• Schedule pulmonary rehabilitation within 3 weeks after discharge to reduce readmissions and improve quality of life; initiating rehabilitation during hospitalization increases mortality 1, 2
• Optimize long-acting bronchodilator therapy (LAMA, LABA, or triple therapy) before discharge 1, 2
• Do not step down from triple therapy (LAMA + LABA + ICS) during or immediately after an exacerbation, as inhaled corticosteroid withdrawal raises recurrent exacerbation risk 1, 2
• Verify correct inhaler technique at discharge 1, 2
• Provide smoking cessation counseling with nicotine replacement therapy and behavioral support for current smokers 1, 2
• Schedule follow-up visit within 3–7 days to assess treatment response 1, 2

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Critical Pitfalls to Avoid

• Never power nebulizers with oxygen in hypercapnic patients; use compressed air and deliver oxygen separately 1, 2
• Never delay NIV when criteria for acute hypercapnic respiratory failure are met (pH < 7.35, PaCO₂ > 45 mmHg persisting >30 minutes) 1, 2
• Never use methylxanthines (theophylline/aminophylline) in acute exacerbations—they add toxicity without benefit 3, 1, 2
• Never continue systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists 3, 1, 2
• Never administer high-flow oxygen without arterial blood-gas monitoring, as this can worsen hypercapnic respiratory failure and increase mortality 1, 2
• Do not use acetazolamide in acute uncompensated COPD exacerbations, as it can worsen acidosis; reserve it for post-hypercapnic metabolic alkalosis after NIV or during ventilator weaning 6