A plan that a patient was put on upon admission for COPD exacerbation and at discharge from the hospital.
Related Articles: COPD Medications.
Acute COPD Exacerbation
Bronchodilators (SAA +SABA)
-Duoneb = ipratropium (SAA) + albuterol (SABA) inhalation solution. Ipratropium is the first-line tx for COPD exacerbation. Albuterol will help if there is a component of reversible bronchoconstriction.
-Nebulizer tx: Duoneb comes as Ipratropium bromide 0.5 mg and albuterol (base) 2.5 mg per 3 mL; i.e. ipratropium bromide / albuterol 0.5mg/2.5mg/3ml neb.
-An alternative is to give the SAA and SABA separately. Ipratropium 0.5mg nebs and albuterol 2.5mg nebs. Use Duoneb if available.
-Give the DuoNeb inhalation solution, 3 mL, Nebulizer, RT Q6hr. If necessary you may give the nebs q1-2h.
-MDI tx: You may give ipratropium MDI 4-8 puffs q1-2h and albuterol MDI 4-8 puffs q1-2h. You may also use Combivent.
Systemic Corticosteroids
-Prednisolone 30-40 mg/d for 10-14 days, or
-Methylprednisolone (Solu-Medrol) 40 mg = 1 mL, IV Push, Q6hr for mild exacerbations, or
-Methylprednisolone 125mg IV q6h x 72hr for more severe exacerbations.
-I’ve seen us use methylPREDNISolone (Solu-Medrol) 80 mg = 2 mL, IV Push, Daily for mild COPD exacerbation patient.
Antibiotics
Infection. Procalcitonin, if elevated will start antibiotics. [If suspicion for infection high, start abx right away]
A 5-day course of either Amoxicillin, TMP-SMX, clarithromycin, doxycycline, antipseudomonal FQ (e.g. Levaquin), etc. All work well. None is proven better than others.
Note: If Pt is allergic to PCN, use Levaquin.
Oxygen
-Increase FiO2 to achieve PaO2 ≥ 55-60 or SaO2 90-93%.
Prevention
Smoking cessation discussed and encouraged.
Flu / Prevnar and Pneumovax
Home Medications & Recommendations at Discharge
LAA: Tiotropium (Spiriva) 18 mcg = 1 cap, Inhalation Oral, Daily
LABA: Arformoterol (Brovana)
Inhaled Corticosteroids: Budesonide (Pulmicort Respules) 0.5 mg = 2 mL, HH Neb, Daily
[Some hospitalists like to start the patient on the LAA, LABA, and inhaled corticosteroid in the hospital together with the SAA and SABA. For severe cases, the patient will continue short-acting treatment at home for a week or two and then only continue the long acting meds and inhaled steroids. They will taper the systemic steroids if it was high dose and over five days.]
Oxygen if PaO2 ≤ 55 mmHg or SaO2 ≤ 89% (during rest, exercise, or sleep) to prevent cor pulmonale. Oxygen tx is the only Rx proven to decrease mortality.