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COPD Inpatient (IPD) Treatment Protocol

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1. Indications for Hospitalization (GOLD 2025/2026)

• Severe dyspnea not responding to initial emergency treatment
• Acute respiratory failure (hypoxemia SpO2 <90%, hypercapnia with pH <7.35)
• Altered mental status / confusion
• Inability to eat, sleep, or ambulate due to dyspnea
• High-risk comorbidities (cardiac arrhythmia, heart failure, pulmonary embolism)
• Inadequate home support or inability to manage at home
• Failure of outpatient management

• Severe dyspnea with incomplete response to emergency treatment
• Confusion, lethargy, coma
• Persistent/worsening hypoxemia (PaO2 <40 mmHg) or respiratory acidosis (pH <7.25) despite NIV
• Failure of NIV or NIV contraindicated
• Need for invasive mechanical ventilation
• Hemodynamic instability

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2. Initial Assessment on Admission

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3. Oxygen Therapy

• Target SpO2: 88-92% (titrated, controlled oxygen - NOT high-flow uncontrolled O2)
• Preferred delivery: Venturi mask (more precise FiO2 delivery than nasal prongs)
• Start at FiO2 24-28% and titrate up to reach SpO2 88-92%
• Reassess ABG 30-60 minutes after starting oxygen
• Avoid hyperoxia - uncontrolled O2 worsens hypercapnia and increases mortality

• Now indicated per GOLD 2026 for acute respiratory failure in COPD
• Viable for mild-moderate respiratory acidosis as a bridge or alternative to NIV
• Reduces hypercapnia, improves oxygenation and comfort
• Monitor same parameters as NIV (Murray & Nadel's, p. 3194)

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4. Bronchodilator Therapy

• SABAs with or without SAMAs are the initial bronchodilators of choice for acute exacerbation
• Nebulized therapy preferred over MDI/DPI during acute illness (dyspnea limits effective inhalation)
• IV aminophylline/theophylline (methylxanthines) are NOT recommended - increased side effects without added benefit (GOLD 2025/2026)
• Initiate long-acting bronchodilators (LAMA/LABA) as soon as possible before discharge to prevent re-exacerbation

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5. Systemic Corticosteroids

• Indication: Moderate to severe exacerbations (hospitalized patients)
• Dose: Prednisolone 40 mg oral once daily (preferred over IV if GI access intact - same efficacy, lower risk)
• Duration: 5 days (no benefit beyond 5 days; reduces hyperglycemia risk)
• If oral route not feasible: Hydrocortisone 100 mg IV every 8 hours or methylprednisolone 0.5 mg/kg IV
• Systemic corticosteroids improve FEV1, oxygenation, and shorten hospital stay (GOLD 2026)

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6. Antibiotic Therapy

• Purulent (green/yellow) sputum
• Increased sputum volume
• Increased dyspnea (in purulent sputum context)
• Mechanical ventilation (invasive or non-invasive)
• Severe exacerbation requiring ICU

• Choose based on local resistance patterns and prior culture results
• Oral route preferred over IV if GI access intact (equivalent efficacy per ERS/ATS guideline)

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7. Non-Invasive Ventilation (NIV / BiPAP)

• pH <7.35 with PaCO2 >45 mmHg (hypercapnic respiratory acidosis)
• Moderate-severe dyspnea with accessory muscle use / paradoxical breathing
• Respiratory rate >25/min despite medical therapy
• Persistent hypoxemia (SpO2 <90%) despite controlled O2

• IPAP: 10-15 cmH2O (titrate up to 20-25 if needed)
• EPAP: 4-5 cmH2O
• FiO2: titrate to SpO2 88-92%
• Interface: oronasal mask preferred

• Hemodynamic instability / cardiac arrest
• Uncooperative or agitated patient
• Loss of consciousness (except COPD encephalopathy where it may still work)
• High aspiration risk (vomiting, facial trauma)
• Non-drained pneumothorax

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8. Invasive Mechanical Ventilation (IMV)

• Failure of NIV trial (pH not improving, worsening mental status)
• Inability to protect airway
• Cardiac or respiratory arrest
• Massive secretions / inability to clear airway
• Severe hemodynamic instability

• Mode: Volume-controlled Assist-Control (VACV)
• TV: ≤8 mL/kg predicted body weight
• RR: 10-14 breaths/min (prevent dynamic hyperinflation)
• Inspiratory time: 0.8-1 second
• PEEP: 5 cmH2O
• FiO2: titrate to SpO2 88-92%
• Tolerate permissive hypercapnia if pH >7.20

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9. Supportive Measures

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10. Monitoring During Admission

• ABG within 1 hour of starting NIV, then 2-4 hourly
• ABG 30-60 minutes after any O2 change
• Sputum cultures if antibiotics initiated
• Blood glucose monitoring (steroid-induced hyperglycemia - treat with insulin)
• Watch for hypokalemia (salbutamol-driven) and hypomagnesemia
• Daily weight if fluid balance is a concern

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11. Exacerbation Severity Classification (GOLD 2026)

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12. Discharge Criteria

• SABA use no more frequent than every 4 hours
• Patient able to walk across room (if previously ambulatory)
• Able to eat, sleep without frequent awakening from dyspnea
• Stable for 12-24 hours on current regimen
• ABG stable and acceptable (not necessarily normal)
• Patient / caregiver understands medications and inhaler use
• Follow-up arranged within 4-6 weeks

• Long-acting bronchodilators (LAMA + LABA dual therapy)
• Add ICS if ≥1 moderate/severe exacerbation + elevated blood eosinophils
• Complete remaining antibiotic/steroid course
• Pulmonary rehabilitation referral (start within 4 weeks of discharge)
• Reassess GOLD group and adjust stable COPD therapy

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13. Post-Discharge Follow-up

• 4-6 weeks: Review symptoms, ABG, spirometry (>6 weeks post-exacerbation), optimize maintenance therapy
• Vaccinations: Influenza (annual), Pneumococcal (PCV15/20), COVID-19
• Long-term oxygen therapy (LTOT): if PaO2 ≤55 mmHg at rest, or <60 mmHg with cor pulmonale/secondary polycythemia
• Consider pulmonary rehabilitation - reduces re-hospitalization and improves functional status
• Exacerbation recovery takes 4-6 weeks; some patients do not return to pre-exacerbation baseline

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