COPD
COPD
Initial therapy of at least 5mg of albuterol containing neb treatment and steroids in ED
CXR is negative for acute findings
Stable vital signs
Partial to poor response to initial therapy
pH between 7.35-7.45 if ABG drawn CO2 < 55
No indication of impending respiratory failure
EKG unchanged from baseline or without evidence of ischemia
If indicated, rule out PE
Ambulatory
Can perform ADL’s
Acute co-morbidities: PNA, CHF exacerbation, cardiac ischemia, arrhythmias, PE
Unstable vital signs
Acute confusion/lethargy
PCO2 > 55 with low pH < 7.35, evidence of narcosis
Oxygen saturation of < 90% on 2 Liters oxygen after 5mg Albuterol
Persistent use of accessory muscles
Previous admissions where LOS consistently > 2 days for COPD exacerbation
Immobility
Unable to perform ADL’s
Medications:
Short Acting Beta Agonists / Muscarinic Agonists
Albuterol and Ipratropium Q4 hours Scheduled
Albuterol Q2 hr PRN
LAMA / LABA Therapy
If patients is already on LAMA +/- LABA therapy continue this
If patient is not on LAMA / LABA but clearly has COPD, consider starting Tiotropium and/or Salmeterol
Steroids
Prednisone 50 mg daily
OR
Inhaled Budesonide 2 mg Q6 hours if side effects of oral steroids deemed to be significant (Maltais et al)
Antibiotics
Only start Abx if patient has all of the following
Increased dyspnea
Increased sputum production
Increased sputum Purulence
Nursing
Continuous pulse oximetry
Supplemental oxygen if needed; keep saturations > 90%.
Check ABG if RR > 28, decrease in oxygen saturation, change in mental status and notify provider
If patient is on home Bipap, make sure this is ordered
Disposition
Stable vital signs
Resolution of symptoms or return to baseline
Pulse ox > 88% on RA or baseline home oxygen
Achieve > 90% SpO2 during the 6 minute walk test
Discharge medications:
Oral Prednisone (50 mg daily) to complete total of 5 days
If not on LAMA/LABA, start at time of discharge
Inhaled Corticosteroid (ICS) only if blood eosinophil count > 300/microliter
Progressive deterioration
Failure to improve
Altered mental status
Persistent new hypoxia
Worsening PCO2 retention if ABG obtained
Pulse ox > 90% on RA or on home oxygen
References:
Maltais F, Ostinelli J, Bourbeau J, Tonnel AB, Jacquemet N, Haddon J, Rouleau M, Boukhana M, Martinot JB, Duroux P. Comparison of nebulized budesonide and oral prednisolone with placebo in the treatment of acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med. 2002 Mar 1;165(5):698-703. doi: 10.1164/ajrccm.165.5.2109093. PMID: 11874817.