COPD Exacerbation (Outpatient)

Clinic A/P, adults

-Mild to moderate COPD exacerbation. Acute respiratory distress 2/2 mild to moderate COPD exacerbation
-Likely 2/2 to ______________________
–Bronchodilators (SAA + SABA): Ipratropium + albuterol nebs or MDI. E.g. Albuterol/ipratropium by metered-dose inhaler TID
–Systemic steroids: PO steroids x 5 days.
–Antibiotic: Levaquin for now. Pt is allergic to PCN.
-Oxygen: Consider home O2. Criteria reviewed. This is the only Rx that is proven to reduce mortality.
-Mucolytics as needed.
-Prevention: Flu shot, Pneumonia shots, smoking cessation encouraged.
-Will consider CXR, CBC & CMP as needed.
-Prevention: Smoking cessation discussed and encouraged.
-Pulmonary rehabilitation discussed. It will decrease dyspnea and fatigue and increase exercise tolerance as well as quality of life.
-Spirometry and PFTs when the patient is stable, not recommended during an exacerbation.

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*** IV and PO steroids have the same bioavailability.

*** Question: How do you classify COPD into mild, moderate and severe?

12-Day Steroid Taper 

Read this detailed A/P I have for COPD Exacerbation treatment that also has doses of medications, etc.

“Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindication because it improves gas exchange, reduces work of breathing and the need for intubation, decreases hospitalization duration and improves survival.” GOLD 2017
** If a corticosteroid-dependent COPD patient develops pneumonia, make sure to cover for Pseudomonas. In patients with chronic lung disease who are taking corticosteroids, Pseudomonas is more common than in those with otherwise healthy lungs. The antibiotics chosen empirically should cover Pseudomonas.

“Intravenous corticosteroids offer no advantages over oral therapy, provided there are no gastrointestinal tract limitations such as poor motility or absorption.

Oral corticosteroid therapy initiated early in a COPD exacerbation reduces the rate of treatment failure, decreases hospitalization rates, improves hypoxia and pulmonary function, and shortens the length of stay for patients requiring hospitalization. Short courses of oral corticosteroids (5–7 days) are as effective as longer ones. Inhaled corticosteroids are ineffective in the treatment of a COPD exacerbation.”ABFM

Reference

Musher DM, Thorner AR: Community-acquired pneumonia. N Engl J Med 2014;371(17):1619-1628.

Click to access od1.pdf

Click to access p607.pdf

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