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COPD

  • Admission orders for exacerbation

    • Admit: Floor if stable, ICR if not
    • Diagnosis: COPD
    • Condition: Stable, Guarded or Critical if ICU
    • Vital Signs: Routine
    • Allergies:
    • Nursing: O2 to maintain sat of 89-91 if pt already on long term O2
    • Diet: Regular
    • Activity: As tolerated
    • Labs:
      • CBC, Chem
      • Blood culture, sputum culture
      • ABG if AMS
      • EKG
      • CXR
    • IV: None if tolerating PO
    • Special:
      • consider BiPAP
        • indication: persistent SOB or respiratory acidosis despite initial therapy
        • contraindication: cardiovascular instability, aspiration risk, AMS, facial injury
    • Medications:
      • Methylprednisolone 125 mg IV now, then 30 mg IV q 6 hours. Transition to 60mg PO qday when tolerated.
      • Albuterol nebulizer q 4 hours
      • Ipratropium nebulizer q 4 hours
      • Albuterol nebulizer q 1 hour prn wheezing or SOB
      • Empiric antibiotics if suspect infection
      • if acute on chronic bronchitis: Trimethoprim-sulfamethoxazole (TMP-SMX) 1 double-strength tab PO bid
      • if CAP: Ceftriaxone 1 g IV q 24 hours and Azithromycin 500 mg IV q 24 hours
      • Nicotine patch 21 mg applied qd
    • Discharge
      • Home oxygen criteria
        • O2 sat < 88 on RA (at rest or with ambulation)
        • or PaO2 < 55
        • or PaO2 55-59 with pulmonary HTN, cor pulmonale, erythrocytosis, edema or AMS
      • Smoking cessation
  • Outpatient tx

    • albuterol and ipratropium prn
    • LABA or tiotropium for anything more than intermittent symptoms
    • smoking cessation
    • exercise, pulm rehab
    • long term O2 if PaO2 < 55 or SpO2 < 88
    • flu, pneumonia vax
  • ED tx

    • albuterol 2.5mg neb q1hr prn
    • ipratropium 500mcg neb q4hr prn
    • methylprednisone 80mg IV bid or prednisone 40mg PO bid x 1 week
    • levofloxacin 750mg PO or IV qday if high risk (age > 65)
    • don't start O2 if pt is not already on long term O2 (hypoxic drive).
  • Dx labs

    • PFTs (low FEV1 and FEV1/FVC, not reversible with albuterol)
    • BNP (r/o CHF)
    • CXR (r/o pneumonia, flat diaphragm suggest COPD)
    • alpha1 antitrypsin (for nonsmokers or young pt)
    • DLCO if PaO2 < 92
  • Px

    • pulm (work of breathing, barrel-chest)
    • cardio
    • clubbing = red flag for cancer, ILD, bronchiectasis

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