Introduction
Diagnosis
Assessment
Treatment
Monitoring
Design and created by Guideline Central in participation with the Post-Acute and Long-Term Care Medical Association.
COPD Management in the Post-Acute and Long-Term Care Setting
Post-Acute and Long-Term Care Medical Association
Publication Date: June 1, 2017
Introduction
- Chronic obstructive pulmonary disease (COPD) is a preventable, treatable disease that is characterized by persistent airflow limitation. Emphysema or destruction of the gas-exchanging surfaces of the lung (alveoli), is a pathological term that is often (but incorrectly) used clinically and describes only one of several structural abnormalities present in patients with COPD. Chronic bronchitis, or the presence of cough and sputum production for at least 3 months in each of 2 consecutive years, remains a clinically and epidemiologically useful term. It does not, however, reflect the major impact of airflow limitation or morbidity and mortality in COPD patients.
* This pocket guide is a companion to the comprehensive AMDA COPD Clinical Practice Guideline
Diagnosis
STEP 1: Screening and Recognition of the Newly Admitted Patient For COPD
Consider evaluating the patient for COPD if any of the following signs, symptoms, or risk factors are noted:
- Abnormal breath sounds (e.g., crackles, prolonged expiratory phase, rales, reduced air movement, rhonchi, wheezing).
- Abnormal pulse oximetry and vital signs from baseline.
- Activity intolerance in performing activities of daily living (ADLs) because of dyspnea.
- Chronic cough, sputum production or dyspnea at rest or with activity.
- Cognitive problems, which may reflect poor oxygenation and/or hypercarbia.
Assessment
STEP 2: Develop a Differential Diagnosis
STEP 3: Assess the Severity of the Patient’s COPD
STEP 4: Assess the Stability of the Patient's COPD
- Patients with COPD should be assessed on admission and periodically during the course of care for worsening symptoms that may reflect acute exacerbation of their disease.
STEP 5: Obtain Input from All Members of the Interprofessional Team
STEP 6: Assess the Patient's Functional Status
STEP 7: Summarize the Patient's Condition
Treatment
STEP 8: Develop an Individualized Care Plan and Define Treatment Goals
STEP 9: Implement Facility-Wide Programs and Policies to Encourage Smoking Cessation
STEP 10: Implement Nonpharmacologic Interventions
Education for cognitively able patients and family members may include:
- Counseling about the disease process,. medication use and the expected outcomes of treatment
- Suggestions for energy-conserving ways to perform ADLs
- Breathing exercises
STEP 11: Prescribe Supplemental Oxygen Therapy if Appropriate
Initiate oxygen therapy for patients with very severe (Stage IV) COPD if:
- PaO2 ≤55 mm Hg or SaO2 ≤88%, with or without hypercapnia or
- PaO2 is between 55–60 mm Hg or SaO2 is >88% if there is evidence of pulmonary hypertension, peripheral edema suggesting CHF, or polycythemia (HCT >55%).
STEP 12: The Patient Should be Protected Against Respiratory Infections
- Pneumococcal vaccines, both PPSV23 and PCV13, are advised for all individuals with COPD >65 yrs.
- Annual influenza vaccine
STEP 13: Implement Appropriate Pharmacologic Interventions
Guiding Principles for COPD Pharmacotherapy in the Long-Term Care Setting
- Medications should be used in combination with nonpharmacologic approaches and initiated only after determining that nonpharmacologic therapies have provided insufficient symptom relief.
- Regular treatment with long-acting bronchodilators is more effective and convenient than regular treatment with short-acting bronchodilators.
- The patient’s response to therapy and side effects should be carefully assessed and treatment adjusted accordingly.
STEP 14: Treat Acute Exacerbations of COPD Promptly
- Only consider antibiotics for moderate or severely ill patients who have increased sputum volume or purulence.
Figure 1. Algorithm for Pharmacological Treatment of Chronic Obstructive Pulmonary Disease (COPD)
Classes of Medications Used to Treat COPDa
| Drug Class | Drug Name and Description | Usual Dosing in Elderly | Costb |
|---|---|---|---|
| Acute Exacerbations of COPD | |||
| Inhaled short-actingβ-agonists,c metered dose inhaler (MDI) (short-acting β-agonists are preferred initial therapy) | Albuterol | 1–2 inhalations every 4–6 h | $ |
| Levalbuterol | 1–2 inhalations every 4–6 h | $$$ | |
| Inhaled short-actingβ-agonists for nebulization (short-acting β-agonists are preferred initial therapy) | Albuterol2.5 mg (3 mL of 0.083% solution) premixed with diluent | 3 mLtid–qid | $ |
| Levalbuterol 0.63 mg/ 3 mL, premixed with diluent | 3 mLtid (every 6–8 h) | $$$ | |
| Inhaled short-actinganticholinergic MDI with or without short-actingβ-agonist (anticholinergic can be added to short-actingβ-agonist therapy if inadequate response) | Ipratropium | 2–3 inhalationsqid | $ |
| Ipratropium/ Albuterol | 1–3 inhalationsqid based on individual agent | $$$ | |
| Inhaled short-actinganticholinergic for nebulization (anticholinergic can be added to short-actingβ-agonist therapy if inadequate response) | Ipratropium 500 mcg (2.5 mL of 0.02% solution), premixed with diluent | 2.5 mL tid–qid (every 6–8 h) | $ |
| Inhaled short-actinganticholinergic and short-actingβ-agonist combination, for nebulization | Ipratopium Albuterol 3 mL premixed solution | 3 mLqid | $$$ |
| Oralcorticosteroids | Prednisone | 40 mg/d PO for 5 d | $ |
| Inhaledcorticosteroid, for nebulization (may be used for nonacidotic exacerbations in patients unable to take medications PO) | Budesonideinhalation suspension, 0.5 mg per inhalation | 3 inhalationsqid for 7–10 d | $$ |
| Chronic Therapy for Stable COPD | |||
| Inhaled long-actinganticholinergic, dry powder inhaler (DPI) orMDI (long-acting agents preferred over short-acting) | Glycopyrrolate | 1 capsule (15.6 mcg) inhaledbid | $ |
| Tiotropium | 1 inhalation daily | $$$ | |
| Umeclidinium DPI | 1 inhalation daily (62.5 mcg) | $$$ | |
| Aclidinium bromide | 1 inhalation (400 mcg)bid | $$$ | |
| Inhaled long-actingβ-agonists, DPI (long-acting agents preferred over short-acting) | Indacaterol | 1 capsule (75 mcg) inhaled daily | $$$ |
| Formoterol DPI | 1 inhalation (12 mcg) every 12 h | $$$ | |
| Salmeterol DPI | 1 inhalation (50 mcg) every 12 h | $$$ | |
| Inhaled short-acting anticholinergic and short-actingβ-agonist combination,MDI | Ipratropium/ Albuterol | See Acute Exacerbations section | $ |
| Inhaled short-actinganticholinergic, for nebulization | Ipratropium | See Acute Exacerbations section | $$ |
| Inhaled short-actingβ-agonist, for nebulization | Albuterol Levalbuterol | See Acute Exacerbations section | $ |
| Inhaled short-acting anticholinergic and short-actingβ-agonist, combination product for nebulization | Ipratopium/ Albuterol(3 mL premixed solution) | 3 mLqid | $$$ |
| Inhaled long-actingβ-agonist, product for nebulization | Arformoterol tartrate (15 mcg/2 mL vials) | 2 mL every 12 h | $$$ |
| Inhaled long-actinganticholinergic DPI and a long-actingβ-agonist | Indacaterol/ Glycopyrrolate | 1 capsule inhaledbid | $$$ |
| Tiotropium/ Olodaterol | 2 inhalations daily | $$$ | |
| Umeclidinium/ Vilanterol | 1 inhalation daily | $$$ | |
| Methylxanthines | Theophylline SR (sustained release) | 100–300 mg PObid | $ |
| Inhaledcorticosteroids,MDI orDPI (for patients with severe COPD and repeated exacerbations, ADDED TO routine bronchodilator therapy) | Beclomethasone dipropionate MDI 40 mcg/inhalation | 1–2 inhalationsbid | $$$ |
| Triamcinolone acetonideMDI | 2–4 inhalations 2–4 times daily (Max: 15 inhalations daily) | $ | |
| Fluticasone DPI | 2–4 inhalationsbid | $ | |
| Fluticasone DPI | 2 inhalationsbid | $$$ | |
| Budesonide DPI 180 mcg/inhalation | 1 inhalationbid | $$ | |
| Inhaledcorticosteroid, for nebulization | Budesonide inhalation suspension 0.5 mg per inhalation | 1 inhalation daily | $$$ |
| Inhaled corticosteroid and inhaled long-actingβ-agonist,combination DPI orMDI (for patients with severe COPD and repeated exacerbations; may be in addition to routine inhaled anticholinergic therapy) | Fluticasone/salmeterol DPI, 250 mcg/50 mcg | 1 inhalationbid | $$$ |
| Fluticastone/vilanterol DPI | 1 inhalationbid | $$$ | |
| Budesonide/formoterol MDI 160 mcg/4.5 mcg | 2 inhalationsbid | $$$ | |
DPI, dry powder inhaler; MDI, metered-dose inhaler
a List not all-inclusive (e.g., some older medications, such as metaproterenol, are not included since their use is no longer considered standard of care for the elderly).
b Indicated pricing is based on current market cost of each drug. Please refer to your individual pharmacy plan if indicated.
c Short-acting β-agonists should also be ordered on a PRN ("rescue") basis for both chronic stable and acute exacerbations of COPD (e.g., "albuterol inhaler 2 puffs PO every 4 h PRN shortness of breath" in addition to routine scheduled therapies).
a List not all-inclusive (e.g., some older medications, such as metaproterenol, are not included since their use is no longer considered standard of care for the elderly).
b Indicated pricing is based on current market cost of each drug. Please refer to your individual pharmacy plan if indicated.
c Short-acting β-agonists should also be ordered on a PRN ("rescue") basis for both chronic stable and acute exacerbations of COPD (e.g., "albuterol inhaler 2 puffs PO every 4 h PRN shortness of breath" in addition to routine scheduled therapies).
NOTE: The scope of products permitted in an emergency or contingency box is frequently state-regulated. Readers should contact their state regulatory body and providing pharmacy to obtain appropriate guidance on the use of emergency and contingency boxes in their state.
STEP 15: Manage Comorbidities Associated With COPD
STEP 16: Consider Specialty Referral
STEP 17: Determine When the Patient's Condition is End-Stage
Prognostic Indicators for Palliative or Hospice Care in Pulmonary Disease
- Disabling shortness of breath at rest
- Increased emergency room visits or hospitalizations
- Low oxygenation at rest (PaO2 <55 mm Hg or SaO2 <88%)
- Progressive weight loss >10% in last 6 months
- Resting heart rate >100 beats/minute
Monitoring
STEP 18: Monitor the Patient's Symptoms and Functional Ability
STEP 19: Monitor the Use of Medications to Treat COPD
STEP 20: Monitor the Facility's Management of COPD Through the QAPI Process
Disclaimer
This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.
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