Acute exacerbation of chronic obstructive pulmonary disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

at presentation

1st line – short-acting bronchodilator

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1st line –

short-acting bronchodilator

Short-acting bronchodilators include short-acting beta-2 agonists (SABAs) and short-acting muscarinic antagonists (SAMAs). Guidelines recommend that these medications are considered first-line therapy and are delivered either by nebulization or by metered-dose inhaler.[1][154][159] SABAs and SAMAs may provide benefit within 15 and 30 minutes, respectively. Optimal dosing of bronchodilators in acute exacerbations of COPD has not yet been determined; however, guidelines generally recommend increasing the dose or frequency of administration if the patient remains symptomatic. After clinical improvement, the time between doses may be increased as tolerated.

SABAs are typically favored as they have a faster onset of action than SAMAs. International guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend SABAs, with or without SAMAs, as the initial bronchodilators to treat an acute exacerbation of COPD.[1] Initial therapy with SABAs may lead to a transient reduction in partial pressure of oxygen (PaO₂).[160] If the initial dose of SABA does not provide sufficient benefit, the frequency of dosing may be increased and a SAMA may be added.[1][161] Nebulized ipratropium (a SAMA) may be given in combination with nebulized albuterol (a SABA). Ipratropium may be used in lieu of albuterol for patients developing significant adverse effects due to SABA use. Levalbuterol may be used in lieu of racemic albuterol and it may be possible to provide levalbuterol less frequently than racemic albuterol in patients with exacerbations. Levalbuterol may be best considered for patients who have adverse cardiovascular effects from albuterol (e.g., tachycardia/tachyarrhythmia).[162]

It is not clear whether the combination of a SABA plus a SAMA provides additional benefit.[163][164] While there is no definitive evidence that the combination improves outcomes, patients may derive symptomatic benefit, plus additional bronchodilation, because these agents work by different mechanisms. Combination therapy is generally recommended for patients who are not improving promptly on a SABA alone.[1]

One systematic review did not find significant differences in FEV₁ when short-acting bronchodilators were delivered by a nebulizer, compared with an MDI (with or without a spacer device), in patients with an acute exacerbation of COPD.[165][256] Patients with severe dyspnea and low inspiratory flow rates may have difficulty achieving proper technique and medication delivery with MDIs; nebulizer treatment may be easier to use for such patients. Technique with MDIs should be observed and a spacer should be used.

Guidelines from GOLD recommend that patients do not receive continuous nebulization, but rather, take 1 or 2 puffs every hour from an MDI (plus spacer) for two or three doses, and then every 2 to 4 hours based on response.[1] If a nebulizer is used to deliver the inhaled drugs, then it should be driven by air, not oxygen, in order to avoid the risk of worsening hypercarbia that may be caused by oxygen-driven nebulization.[1][156]

There is insufficient evidence to determine whether MDIs or the aerosol nebulizer technique is the optimal method of delivering bronchodilators to adults with COPD exacerbations who are receiving mechanical ventilation via endotracheal tube.[257]

There are as yet no clinical trials to clearly guide whether or not long-acting bronchodilators should be continued during acute COPD exacerbations. Although discontinuation of a maintenance therapy might potentially contribute to worsening symptoms and/or lung function, regular frequent administration of short-acting bronchodilators, in addition to long-acting bronchodilators of the same class, has the potential to increase the risk of medication-related adverse effects, such as arrhythmia, urinary retention, and constipation. The current GOLD report recommends continuing inhaled long-acting bronchodilators during an exacerbation, or starting them as soon as possible before discharge from hospital.[1] Clinical judgment should dictate whether or not to continue long-acting bronchodilators during acute hospitalizations for COPD when patients are receiving short-acting bronchodilators four or more times per day. Consideration should be made as to whether adjustments to pre-hospitalization drug regimens are needed, based on recommendations for step-up therapy to reduce future risk of exacerbations.[1]

Optimal dosing of bronchodilators in acute exacerbations of COPD has not been established. Adjust dose according to clinical symptoms and adverse effects. Higher or more frequent dosing may be required.

Primary options

albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) inhaled every 1 hour for 2-3 doses, followed by 90-180 micrograms (1-2 puffs) every 2-4 hours when required; (0.083% or 0.5% nebulizer solution) 2.5 mg inhaled via nebulizer every 1 hour for 2-3 doses, followed by 2.5 mg every 2-4 hours when required

albuterol inhaled : (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) inhaled every 1 hour for 2-3 doses, followed by 90-180 micrograms (1-2 puffs) every 2-4 hours when required; (0.083% or 0.5% nebulizer solution) 2.5 mg inhaled via nebulizer every 1 hour for 2-3 doses, followed by 2.5 mg every 2-4 hours when required

levalbuterol inhaled: (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) inhaled every 1 hour for 2-3 doses, followed by 45-90 micrograms (1-2 puffs) every 2-4 hours when required; (0.021% or 0.042% nebulizer solution) 0.63 to 1.25 mg inhaled via nebulizer every 1 hour for 2-3 doses, followed by 0.63 to 1.25 mg every 2-4 hours when required

levalbuterol inhaled : (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) inhaled every 1 hour for 2-3 doses, followed by 45-90 micrograms (1-2 puffs) every 2-4 hours when required; (0.021% or 0.042% nebulizer solution) 0.63 to 1.25 mg inhaled via nebulizer every 1 hour for 2-3 doses, followed by 0.63 to 1.25 mg every 2-4 hours when required

-- AND / OR --

ipratropium bromide inhaled: (17 micrograms/dose inhaler) 34 micrograms (2 puffs) inhaled every 4-6 hours when required; (0.02% nebulizer solution) 0.5 mg inhaled via nebulizer every 6-8 hours when required

ipratropium bromide inhaled : (17 micrograms/dose inhaler) 34 micrograms (2 puffs) inhaled every 4-6 hours when required; (0.02% nebulizer solution) 0.5 mg inhaled via nebulizer every 6-8 hours when required

Primary options

albuterol inhaled : (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) inhaled every 1 hour for 2-3 doses, followed by 90-180 micrograms (1-2 puffs) every 2-4 hours when required; (0.083% or 0.5% nebulizer solution) 2.5 mg inhaled via nebulizer every 1 hour for 2-3 doses, followed by 2.5 mg every 2-4 hours when required

levalbuterol inhaled : (45 micrograms/dose inhaler) 45-90 micrograms (1-2 puffs) inhaled every 1 hour for 2-3 doses, followed by 45-90 micrograms (1-2 puffs) every 2-4 hours when required; (0.021% or 0.042% nebulizer solution) 0.63 to 1.25 mg inhaled via nebulizer every 1 hour for 2-3 doses, followed by 0.63 to 1.25 mg every 2-4 hours when required

-- AND / OR --

ipratropium bromide inhaled : (17 micrograms/dose inhaler) 34 micrograms (2 puffs) inhaled every 4-6 hours when required; (0.02% nebulizer solution) 0.5 mg inhaled via nebulizer every 6-8 hours when required

Back to drug information with added comorbidities

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Show drug information for a patient with no comorbidities

Primary options

albuterol inhaled

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

levalbuterol inhaled

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

-- AND / OR --

ipratropium bromide inhaled

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Consider – systemic corticosteroid

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Consider –

systemic corticosteroid

Treatment recommended for SOME patients in selected patient group

Systemic (oral or intravenous) corticosteroids should be considered after initial treatment with short-acting inhaled bronchodilators.[1][154][159] For patients able to take oral medications, intravenous corticosteroids do not appear to provide any significant benefit over those taken orally.[166][167][168][169] However, some patients may require intravenous administration if they cannot tolerate oral therapy (e.g., if they are vomiting).

Systemic corticosteroids have been associated with greater early (within 3 days) improvement in FEV₁, improved oxygenation, faster recovery time, decreased duration of hospitalization, and decreased rate of treatment failure and relapsed disease.[1][166][167][170][171][172] However, there is no evidence that the use of corticosteroids has an effect on rates of mortality.[166] In addition, corticosteroids are associated with increased risk of pneumonia, sepsis, and death.[173] They should only be used in patients with significant exacerbations.[1]

The American Academy of Family Physicians (AAFP) recommends systemic corticosteroids for adults with COPD exacerbation to reduce clinical failure. Owing to insufficient evidence, the AAFP does not make recommendations on dose, route of administration, or duration of treatment.[159] It is not known whether tapering systemic corticosteroids provides any clinical benefit apart from likely avoidance of adrenal insufficiency. One randomized controlled trial showed that 5 days’ treatment of prednisone was noninferior to 14 days’ treatment with regard to the risk of exacerbations in the subsequent 6 months.[174] One Cochrane systematic review concluded that five days of oral corticosteroids is likely to be sufficient for acute exacerbations of COPD, and that it is unlikely that shorter courses of systemic corticosteroids (of around 5 days) lead to worse outcomes than longer courses (10-14 days).[175] [ ] This 5-day regimen is recommended by the Global Initiative for Chronic Obstructive Lung Disease guidelines.[1] The Department of Veterans’ Affairs recommends prednisone for 5-7 days.[154] An equivalent oral dose of methylprednisolone may be used. Joint guidelines from the European Respiratory Society and American Thoracic Society recommend a short course (≤14 days) of oral corticosteroids for ambulatory patients with an exacerbation of COPD.[176] One systematic review found no difference in risk of treatment failure or relapse, likelihood of an adverse event, length of hospital stay, or lung function, at the end of short (approximately 5 days) and longer (10-14 days) courses of systemic corticosteroids.[166]

The balance of risks and benefits of corticosteroids for people with milder exacerbations is uncertain. The eosinophil count may prove to be useful in determining who should receive corticosteroids for acute exacerbations of COPD; systemic corticosteroids may be less effective for acute exacerbations of COPD among patients with lower blood eosinophil levels.[1][21][177][178][179]

The benefit of systemic corticosteroid therapy for people with acute exacerbations of COPD with associated respiratory failure requiring mechanical ventilatory support is also unclear. One randomized controlled trial found no difference in intensive care unit (ICU) mortality, duration of mechanical ventilation, or ICU length of stay between patients who received prednisone versus the control group who did not, yet those who received prednisone had a higher risk of hyperglycemia.[180]

The presence of pneumonia as a cause of respiratory decompensation in a patient with COPD does not necessarily imply the presence of a COPD exacerbation per se (i.e., the presence of worsened airflow limitation related to airways inflammation and/or bronchoconstriction), and as such, careful consideration should be given as to whether systemic corticosteroids are warranted in such patients.

Diabetes is common in patients with COPD, and the need for treatment of hyperglycemia is more frequently encountered when patients receive systemic corticosteroids.[166][171]

Manage your patient’s diabetes when they are taking corticosteroids

Giving corticosteroids to someone with diabetes will worsen their glycemic control, so continue to test blood glucose at least four times a day (based on expert opinion).

For patients with diabetes, use the same doses of corticosteroid as for patients without diabetes, but adjust diabetes medication, as their glycemic control will get worse.
Treat hyperglycemia, if it occurs, taking into account the type of corticosteroid.[293]
- NPH (neutral protamine Hagedorn) insulin is often added to the individual’s basal-bolus insulin or oral glucose-lowering medication if an intermediate-acting corticosteroid (e.g., prednisone) is started. The American Diabetes Association (ADA) recommends NPH insulin at the same time as the corticosteroid dose, as the action peak of 4 to 6 hours coincides with peak plasma level of the intermediate corticosteroid.
- The addition of long-acting insulin may be needed for an individual starting a long-acting corticosteroid (e.g., dexamethasone), or for those having multiple doses or continuous doses of a corticosteroid.
- Increases in correction insulin and prandial insulin (if eating) may be needed, along with basal insulin, for an individual starting a high dose of a corticosteroid. Be aware of the possibility of nocturnal or early morning hypoglycemia. Consider adjusting basal insulin and avoid bed-time correctional doses of rapid-acting insulin (based on expert opinion).
- If a continuous intravenous insulin infusion is being used in a critically ill patient, follow glycemic management protocols and procedures to treat persistent hyperglycemia.[294]
- If your patient has type 1 diabetes and their capillary blood glucose does not come down below 200 mg/dL (11.1 mmol/L) for more than 24 hours, check bicarbonate and anion gap, and if anion gap acidosis is present, check beta-hydroxybutyrate (or blood ketones).

When you taper the corticosteroid dose, glycemic control will likely improve, which may require weaning the dose of titrated diabetic medication back to the pre-corticosteroid regimen.[295]

If the diabetes medication is not appropriately weaned off, your patient will be at a high risk of developing hypoglycemia. Communicate the strategy for titration with the outpatient team on discharge.
The duration of action for a particular corticosteroid will determine the period of effect on glycemic control.
- Intravenous corticosteroids typically have shorter half-lives, which means glycemic control returns to pre-corticosteroid levels within 24 hours.
- Oral corticosteroids, especially if long acting, (e.g., dexamethasone) may take a few days.

Monitor for psychiatric complications of corticosteroids

Corticosteroids are indicated as an immediate treatment in certain acute conditions, as well as some chronic conditions, but it is important to be aware that corticosteroids may have adverse psychiatric effects.[296]

Although all patients should be monitored for these effects, the risk of depression, mania, panic disorder, or suicide during corticosteroid therapy has been reported to be higher in people who are already living with these conditions, but not consistently so.[297]

If the clinical situation allows:

Check previous response to corticosteroids
- Past incidence of psychiatric complications during corticosteroid therapy may increase the risk of recurrence in subsequent treatments.[297]

Monitor for psychiatric adverse effects.

These may vary in severity and include among others:[298]
- Anxiety and insomnia
- Severe mood disorders, including manic states[296]
- Cognitive impairment.
Effects seem to be dose-related and are more common with long-term regimens, long-acting formulations, and in older patients.[297] This also stands true for patients who have neuropsychiatric adverse effects related to discontinuing long-term corticosteroid therapy.[299]
Manic episodes and delirious states are the most common psychiatric adverse effects when starting corticosteroid treatment, whereas depression is most common during chronic therapy.[297][300]
Be aware of a possible withdrawal reaction, which may present with weakness, fatigue, gastrointestinal symptoms, and delirium, as well as with psychiatric complications such as depression, when discontinuing corticosteroids.[299]

If your patient develops psychiatric complications related to corticosteroids, ask for a psychiatric consult for advice on appropriate management (based on expert opinion).

This may include adjusting dose or earlier discontinuation of the corticosteroid if the clinical situation allows.[297]
If the dose of the corticosteroid cannot be adjusted or the corticosteroid cannot be discontinued, pharmacologic treatment of the psychiatric adverse effects may be necessary (based on expert opinion).

Primary options

prednisone: 40 mg orally once daily

prednisone : 40 mg orally once daily

prednisone: 40 mg orally once daily

methylprednisolone sodium succinate: 40-60 mg intravenously every 24 hours

methylprednisolone sodium succinate : 40-60 mg intravenously every 24 hours

methylprednisolone sodium succinate: 40-60 mg intravenously every 24 hours

Consider – airway clearance techniques

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Consider –

airway clearance techniques

Treatment recommended for SOME patients in selected patient group

Selected airway clearance techniques, such as mechanical vibration and non-oscillating positive expiratory pressure devices, may improve sputum clearance in some patients with copious secretions, or concurrent bronchiectasis, and may slightly reduce short-term risk of need for ventilatory assistance.[184] [ ] However, they are not uniformly helpful.[185] Other clearance techniques, such as manual chest wall percussion, are also either not routinely helpful or may have detrimental effects.[186][187][188] There is as yet no proven benefit of airway clearance techniques on long-term outcomes following COPD exacerbation, such as reduction in subsequent exacerbation risk.[184] [ ]

Consider – oxygen

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Consider –

oxygen

Treatment recommended for SOME patients in selected patient group

Oxygen therapy is recommended for patients with acute exacerbations who are hypoxemic (partial pressure of oxygen [PaO₂] <60 mmHg, oxygen saturation [SaO₂] <90%). Oxygen should be applied with caution to prevent further hypercapnia. Blood gas and pulse oximetry should be checked on presentation, and then after 30 to 60 minutes, to ensure satisfactory oxygenation and to check for carbon dioxide retention and/or respiratory acidosis.[1][133] Controlled oxygen should be titrated to a target saturation of 88% to 92% as COPD patients are considered at risk for hypercarbic (type 2) respiratory failure.[1][133] Careful titration of supplemental oxygen, even in the prehospital setting, is important to prevent worsening respiratory acidosis, which may increase mortality.[189]

Oxygen is best administered in a controlled fashion via a high-flow Venturi mask to deliver 24% to 28% oxygen.[133]

Excessive oxygen therapy may lead to worsening hypercapnia, acidosis, and respiratory failure, due to worsening V/Q mismatch and decreased CO₂-carrying capacity of oxygenated erythrocytes (Haldane effect). For this reason, oxygen delivery via a high-flow Venturi mask is favored over nasal prongs, as nasal prongs are less accurate and deliver higher inspired oxygen concentrations.[1][190] Nasally-delivered high-flow oxygen may be a suitable alternative to noninvasive mechanical ventilation for some patients with severe COPD exacerbations in the intensive care unit setting.[1]

Oxygen therapy may be discontinued when the patient is able to maintain their target oxygen saturation on room air.[133] Oxygen saturation should be checked at rest, with exertion, and during sleep (if possible) prior to discharge for hospitalized patients, in order to determine if supplemental oxygen will be newly needed in the home, or if changes to prior oxygen prescription are necessary.

Consider – supportive care

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Consider –

supportive care

Treatment recommended for SOME patients in selected patient group

Depending on the patient’s clinical condition, the following may also need to be addressed: monitoring and correction of fluid balance (e.g., in patients with heart failure); treatment of any comorbidities (e.g., lung cancer, cardiovascular disease, osteoporosis, depression); thromboprophylaxis; nutritional supplements; smoking cessation (e.g., nicotine replacement therapy).[1]

Assess fluid status and manage fluid balance particularly closely

Be aware that hypovolemia may be difficult to assess in a person with heart failure and/or chronic kidney disease (CKD).

As with any patient presenting acutely, look for signs of volume depletion on physical exam, by assessing:[301]

Vital signs:
- Blood pressure, (particularly systolic blood pressure [SBP] and mean arterial pressure)
- Pulse
- Orthostatic vital signs
Mucus membranes
Capillary refill time
Jugular venous distension.

Consider point of care ultrasound (POCUS), which may give further information of the etiology of heart failure and volume status. There are several protocols that may be appropriate for each clinical situation. For example, the Rapid Ultrasound for Shock and Hypotension (RUSH) exam, commonly performed by clinicians in the emergency setting, is a noninvasive method that may help determine the cause of shock.[302] Depending on the clinical circumstance, a full echocardiogram and/or other investigations may subsequently be ordered.

More info: The RUSH exam

The RUSH exam involves a three-part physiologic assessment using point of care ultrasound (POCUS):[303]

1. The pump, i.e., the cardiac status
- Evaluate cardiac status by looking for: pericardial effusions and cardiac tamponade, left ventricular contractility, and right ventricular size
2. The tank, i.e., the effective intravascular volume status
- Assess the fullness of the tank by examining the inferior vena cava (IVC) and/or internal jugular veins
- Evaluate for "leakiness" of the tank, or free fluid in the abdominal and thoracic cavities, by performing Focused Assessment of Sonography for Trauma (FAST) and thoracic ultrasound to assess for fluid in the abdominal and thoracic cavities[304][305]
- Assess compromise of the tank by assessing for pneumothorax
3. The pipes, i.e., the arterial and venous sides of the circulatory system
- Assess the aorta looking for aortic aneurysm, rupture, dissection
- Assess lower extremity and/or upper extremity veins for deep vein thrombosis.

Other variations of RUSH have been described.[302]

Practical tip

Establish your patient's baseline blood pressure as the fall from baseline and association with any symptoms (such as presyncope or syncope) is more significant than absolute systolic blood pressure (SBP).

Heart failure

Be aware that an SBP of <90 mmHg may suggest hypotension, but a patient on medication for chronic heart failure can have a baseline SBP of <90 mmHg.

Consider consultation with a specialist.

A patient with heart failure may require fluid resuscitation. If needed, this should include close fluid balance monitoring because there is a significant risk of pulmonary edema with fluid resuscitation. Invasive monitoring can be a valuable tool in certain circumstances in patients with heart failure, particularly (based on expert opinion):

With a suspected low output or cardiogenic shock state
With massive fluid overload, when high doses of diuretic are needed or with diuretic resistance
When unable to establish volume state
When titrating inotropes.

CKD

A patient with CKD who is hypovolemic needs immediate fluid resuscitation.

Reassess your patient after initial fluid challenge and further address the cause of hypovolemia
If they do not rapidly stabilize:
- Consider activating the rapid response team and obtaining specialist consultation
- Consider transferring your patient to an intensive care setting where hemodynamic monitoring is possible (based on expert opinion).

Continue to monitor fluid balance particularly closely

Accurate monitoring of volume status is essential in a person with heart failure and/or chronic kidney disease (CKD).[306]

There is a significant risk of pulmonary edema with fluid resuscitation in a patient with heart failure and/or CKD, so monitor closely.
Monitoring should include:
- Regular clinical assessment of volume status (pulse, BP, jugular venous distension [JVD], and check for pulmonary and peripheral edema)
- Fluid balance (input/output chart) and daily weight
- BUN and serum creatinine to monitor kidney function, at least daily.
Consider bladder catheterization if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Patients with greater clinical complexity, such as those with heart failure and/or advanced CKD may need admission to the intensive care unit for more invasive monitoring and interventions. If noninvasive bedside assessments are not adequate for monitoring, consider a central venous pressure catheter or pulmonary artery catheter.[306][307][308]

Practical tip

Always be mindful of signs of cardiogenic shock including elevated lactate, hypotension, worsening end-organ function, and altered mental status. Early and aggressive management is key to survival and requires immediate involvement of specialists including heart failure specialists (based on expert opinion).

De-escalation

It's important to know when to de-escalate fluid therapy. In a patient with heart failure and/or CKD, judicial use of fluids is crucial to preventing clinically significant volume overload. De-escalate when:

Your patient is euvolemic
The problem requiring fluids has been successfully reversed.

Monitor volume status consistently to try to avoid volume overload.

If a patient begins to show signs of volume overload with fluid (signs include elevated pulse rate, elevated respiratory rate due to pulmonary edema, JVD with peripheral edema, and decreased oxygen saturation):

Immediately stop fluid administration
Consider consultation with specialist
Consider intravenous diuretics, and
Arrange an urgent chest x-ray if pulmonary edema is suspected (based on expert opinion).

Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).

Recommendations from an intensive care specialist and/or cardiologist and/or nephrologist may be needed.

Mental status exam

Perform a mental status exam as the clinical situation allows (based on expert opinion).

The mental status exam is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.

Consider assessing current symptoms of depression using the PHQ-9 questionnaire.[309][310]

The PHQ-9 questionnaire can be used as a reliable and valid measure of depression severity in patients with a known diagnosis of depression, as well as a screening tool.
This can be self-administered or administered by the clinician, and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.

Take into account other factors that may be influencing the patient's mental status (e.g., the effect of any illicit drug use or alcohol).[310][311]

In particular, consider whether symptoms of depression could be part of the acute medical illness (based on expert opinion).

Consider psychiatric consult

Consider psychiatric consult for any patient with comorbid depression who is admitted to the hospital with an acute condition.

Consult is strongly advised in patients with severe symptoms of depression or additional symptoms such as suicidal ideation, homicidal ideation, catatonia, psychosis (based on expert opinion).
Consult may not be required if there are no concerns that depression and/or its management (e.g., medication) may be affecting the acute condition (based on expert opinion).
Accidents of unclear circumstances, self-injurious behaviors, and/or suicide attempts (including alleged "accidental" overdose of medication) should trigger clinical suspicion of comorbid mental health disorder (based on expert opinion).

Ensure your patient has adequate support with their treatment post-discharge.

Keep in mind that the psychological impact of comorbid depression may be associated with poor adherence with recommended physical health treatments, from medication to rehabilitation.[312][313][314] This may lead to worse clinical outcomes, including higher readmission risk.[315][316]
Most importantly, affective symptoms, including depression, have been linked with excess mortality, though a causal link remains to be proven.[317][318]

Anticoagulation in your patient with CKD

Review your drug information source or discuss with the hospital pharmacist for details when prescribing an anticoagulant in your patient with reduced kidney function (CKD, acute kidney injury).

Patients with impaired kidney function may have an increased risk of bleeding with anticoagulants and careful patient monitoring is needed.[319][320]
Depending on the degree of impairment of your patient’s kidney function and the anticoagulant prescribed, you may need to:[319]
- Adjust the dose
- Avoid certain anticoagulants.

Manage tobacco dependence

If your patient currently uses tobacco, assess their tobacco use and provide assistance and support with tobacco cessation interventions.[321][322][323]

Offer nicotine replacement therapy (NRT) and/or other tobacco cessation pharmacotherapies for all patients with tobacco dependence if there are no contraindications.[321][322][323][324] For admitted patients, NRT should be offered on admission. This is particularly important as they may be unable to use tobacco due to both their acute illness and admission to the hospital.

Advise:

That nicotine is highly addictive and nicotine withdrawal can be extremely distressing and uncomfortable.[322]
NRT prevents rapid withdrawal.[322]
That there are a number of highly effective treatment options that offer the best chance of stopping smoking.[321][322][323]

NRT should combine long-acting formulations (e.g., transdermal patches) together with short-acting formulations (e.g., chewing gum, lozenges, nasal spray) as combination NRT is more effective than a single NRT.[321][325][326]

Ensure a sufficient dose of NRT is prescribed to adequately address withdrawal symptoms.[327]
Ask the patient how many cigarettes they smoke per day; this may determine the starting dose of NRT.
Ask about the type of tobacco product used, including e-cigarettes, water pipe use, and other smokeless tobacco products (snuff, ground, or chewing tobacco), as use of these products also results in nicotine addiction.
Check drug information sources for any contraindications or cautions, particularly if your patient has one or more comorbidity and/or is hemodynamically unstable.
Assess for symptoms of withdrawal daily (based on expert opinion).

For any patient who has an intention to quit using tobacco, consider using varenicline and NRT together as this is a highly effective combination for tobacco cessation in adults.[328] Combination therapy for tobacco dependence is more effective than use of a single agent.[326]

One Cochrane Review found high-certainty evidence that varenicline is an effective treatment for tobacco dependence.[329] The same review found that people taking varenicline likely have an increased chance of a more serious adverse effect (e.g., cardiac) that could result in hospital admission; however, these are still rare (2.7% to 4% of people on varenicline, compared with 2.7% of people not taking varenicline) and may include events that are unrelated to varenicline.[329] Check drug information sources for a full list of contraindications and cautions or seek pharmacist advice.
Mental health illness is NOT a contraindication to prescribing varenicline. However, varenicline should be used with caution in people with a pre-existing psychiatric illness as it may worsen symptoms.
Bupropion is an alternative option to varenicline for tobacco cessation but is less likely to result in successful quitting.[329] Consider the potential for drug-drug interactions.

Start tobacco cessation counseling while the patient is in hospital and continue this, along with pharmacotherapy and behavioral support, after discharge.[324] Quit rates for hospitalized patients are highest when smoking cessation counseling begins in hospital and continues for more than a month after discharge.[324]

Ensure your patient has follow-up with their primary care practitioner or addiction medicine physician to continue treatment for tobacco dependence.

Practical tip

Note that COPD is commonly underdiagnosed in patients with tobacco dependence.[330] If you have concern that your patient may have undiagnosed COPD, ensure discharge instructions include testing to complete evaluation for COPD (based on expert opinion).

See Smoking cessation for more information.

Plus – review current treatment for depression in your patient with COPD

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Plus –

review current treatment for depression in your patient with COPD

Treatment recommended for ALL patients in selected patient group

Review the drugs used to manage your patient’s mental health, ensuring you have an up-to-date list. Consider that antidepressants may be used in the treatment of conditions other than depression, and drugs other than antidepressants may be used to treat depression. The information here refers to antidepressants.

Continue the patient’s usual antidepressant, unless there are good reasons not to (based on expert opinion).

If antidepressants are stopped abruptly, the patient may develop antidepressant discontinuation syndrome.[331]
The severity of the symptoms of discontinuation may vary, but they may be unpleasant and may complicate the management of the acute medical condition.

The Global Initiative for Chronic Lung Disease (GOLD) states that there is no evidence that depression should be treated any differently in people with COPD.[332]

A Cochrane review found insufficient evidence on antidepressants for treating COPD-related depression and recommended better research.[333]
There is an increased incidence of mental health problems in people with obstructive and restrictive lung disease, including COPD.[334] Comorbid depression is associated with more frequent exacerbations, readmissions, and premature mortality.[335][336]

When reviewing current medications, consider:

Current and previous adverse effects
Recent changes in dose
Recent medication changes from a different drug class
The specific diagnostic subtypes of depression when prescribing medications (e.g., it is likely that patients suffering from psychotic depression would be coprescribed an antipsychotic)
Augmenting strategies that may be used when treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).

Consider drug-drug interactions.

Antidepressants (particularly those that inhibit the CYP450 pathway) may cause significant interactions with drugs used for other conditions.[337]

Consider psychiatric complications when prescribing nonpsychotropic drugs.

Take particular care when prescribing anticonvulsants, antiparkinsonian drugs, and corticosteroids.

Consider adverse effects, which may include the following:

Hyponatremia, caused by antidepressants, especially SSRIs, and compounded by other coprescribed drugs (e.g., diuretics).[338][339][340][341] Review your patient’s serum electrolyte results and consider antidepressants as a potential contributing factor if they have hyponatremia.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, ocular clonus or inducible clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >100.4°F [>38°C]), especially with polypharmacy and/or overdose of a serotonergic agent.[342][343] See Serotonin syndrome.
- Be particularly aware of increased risk of serotonin syndrome in patients with kidney failure on SSRIs.[344][345]
Hepatotoxicity.[346] Adjust doses of antidepressants in patients with hepatic impairment as necessary.
- However, antidepressants are rarely the cause of hepatic impairment.[346]
Prolonged QTc, arrhythmias, increased heart rate, postural hypotension with tricyclic antidepressants.[347][348] Obtain an ECG, especially in people at risk of arrhythmias.[349]
Gastrointestinal bleeding. SSRIs are associated with an increased risk of gastrointestinal bleeding.[338][350][351] Risk is particularly increased when coprescribed with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or oral anticoagulants.[351][352][353] Monitor closely and consider gastroprotection with proton-pump inhibitors if SSRI use cannot be avoided (based on expert opinion).

This list of adverse effects is not exhaustive - consult your drug information source or hospital pharmacist for further information, and consider a psychiatric consult for advice.

Ask your patient about nonpharmacologic treatments for their depression and check the current level of support in the community.

This may include other health professionals involved in their care, charities, family and social networks, and psychological therapy.
Cognitive behavioral therapy (CBT) may be beneficial in treating COPD-related depression.[354]
Be aware that pulmonary rehabilitation may not only improve exercise capacity and quality of life following an exacerbation of COPD, but may have a positive effect on symptoms of depression.[332][355]

Evidence: Psychological therapies for depression in people with COPD

A Cochrane review of 13 randomized controlled trials (RCTs) (n=1500 patients) investigating the efficacy of psychological therapies concluded that a CBT approach may be effective for treating COPD-related depression, but the evidence is limited. Relaxation therapy may also have beneficial effects on both dyspnea and wellbeing.[354]

Most participants had moderate to severe COPD.
A meta-analysis of six of these RCTs (764 participants) found that CBT-based psychological therapy reduced depressive symptoms more than "no intervention" (standardized mean difference 0.19; 95% CI 0.05 to 0.33; P=0.009) and the quality of the evidence was rated as very low due to clinical and methodological heterogeneity.
Overall, there was no significant improvement in quality of life (QoL) with psychological therapies (most CBT-based) compared with no intervention. However, pooled data from two trials that used the same measure for QoL found that CBT was associated with a higher QoL compared with no intervention.

Practical tip

Be aware that smoking cessation or switching from tobacco smoking to alternatives (including nicotine replacement therapy) may result in a change to the plasma concentration of any psychotropic medication the patient may be taking (e.g., for depression). This is because nicotine replacement therapy does not impact hepatic enzyme activity like tobacco smoking.[356][357][358] Consider whether any dose adjustment of the psychotropic is required, and consult the hospital pharmacist if needed.

Plus – take your patient's comorbidities and level of frailty into account when deciding on setting for care

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Plus –

take your patient's comorbidities and level of frailty into account when deciding on setting for care

Treatment recommended for ALL patients in selected patient group

Your patient's comorbidities are an important factor to consider when deciding whether they can be treated at home or require hospital admission and/or specialist assessment.

Take into account the severity and stability of your patient's overall clinical condition and their ability to self-care at home.
Even a mild illness in patients with frailty or those with chronic conditions may lead to a decline in functional ability such that they are unable to care for themselves at home and support from caregivers may not be immediately available.
- Use the Clinical Frailty Scale (CFS), if your patient is ≥65 years old, to assess their level of frailty as part of a holistic assessment where appropriate.[359][360] Dalhousie University: Clinical Frailty Scale Opens in new window
- Do not use the CFS to assess younger patients, or those with disabilities that reflect single-system problems (e.g., spinal cord injury).[361]
Assess your patient's living situation and social support.[362] Canadian Geriatrics Society: Public launch of the geriatric 5Ms Opens in new window
- Ensure they have an appropriate level of care (e.g., caregiver services at home, or institutional care) if you are considering continuing their treatment at home, or discharge from the hospital.
- Make sure they have adequate follow-up and clear self-care instructions including information on when to call their doctor (based on expert opinion).

Practical tip

If your patient with frailty is an older adult, consider the "Geriatric 5Ms" when deciding on setting of care or identifying patients who would benefit from specialist geriatric input. The 5Ms are:[363][364][362][365] Canadian Geriatrics Society: Public launch of the geriatric 5Ms Opens in new window

Mind (mentation, dementia, depression, and delirium)
Mobility (gait, balance, and falls prevention)
Medications (polypharmacy, deprescribing, optimal prescribing, and adverse medication effects and medication burden)
Multicomplexity (multimorbidity and complex psychosocial situations)
Matters Most to Me (each individual's health outcome goals and care preferences).

Plus – withhold antihypertensives and/or diuretics if hypotensive

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Plus –

withhold antihypertensives and/or diuretics if hypotensive

Treatment recommended for ALL patients in selected patient group

Consider withholding antihypertensives and/or diuretics in a patient with a history of hypertension, coronary artery disease, heart failure, stroke, or chronic kidney disease (CKD) if your patient:

Is hypotensive or in shock, or has a blood pressure ≥40 mmHg lower than their baseline, or
Has developed orthostatic hypotension or has postural symptoms (based on expert opinion).
- Orthostatic hypotension is defined, by consensus, as a fall in systolic blood pressure ≥20 mmHg and/or a fall in diastolic blood pressure ≥10 mmHg on assuming an upright posture.[366]
- In people with classic orthostatic hypotension, the blood pressure change occurs within 3 minutes of standing.[367] In practice, take standing blood pressure after the person has been standing for at least 1 minute (based on expert opinion).

Establish your patient's baseline blood pressure and assess volume status.

Patients with treated heart failure may have chronically low blood pressure (e.g., systolic blood pressure ≤90 mmHg). If their systolic blood pressure falls by >10-15 mmHg and is associated with symptoms (such as presyncope or syncope), it may be appropriate to withhold medications that may lower blood pressure but have no or little prognostic benefit for heart failure (such as amlodipine, doxazosin).
- Consider changing the time of administration of medication that has a prognostic benefit for heart failure (e.g., sacubitril/valsartan, beta-blockers) to night time, or splitting or reducing the dose (based on expert opinion).
- Consider consultation with a specialist.

If diuretics are withheld in a patient with heart failure and/or CKD, close monitoring is needed as fluid can quickly accumulate.

Be aware that sodium-glucose cotransporter-2 (SGLT2) inhibitors, a class of medication with a prognostic benefit for both heart failure and CKD, also have a weak diuretic effect.[368]

If antihypertensives or diuretics have been withheld during the acute illness, consider restarting them before discharge if clinically appropriate (based on expert opinion).

Restart one at a time at a lower dose and ask their primary care physician (PCP) to titrate back to normal dose.
- Most patients won't tolerate restarting all medications at the original doses simultaneously.
- If it is not clinically appropriate to restart these medicines before discharge, ensure that the patient has follow-up to decide when the medications can be reintroduced.
- Ensure you have communicated clearly to the PCP at discharge.

Plus – monitor comorbidities during hospital stay

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Plus –

monitor comorbidities during hospital stay

– review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

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review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

Treatment recommended for ALL patients in selected patient group

Check your patient’s blood glucose on admission and HbA1c (if no result is available from the previous 3 months).[293][369]

Exclude hypoglycemia, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycemic state (HHS).
Admission HbA1c may give you an indication of your patient’s previous diabetes control and may influence your treatment on discharge.
Test for blood beta-hydroxybutyrate or ketones if:[370][371]
- Your patient was taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor before unplanned hospitalization, and/or
- There is acidosis, an increased anion gap, nausea/vomiting or a combination of these.

Never stop basal insulin (long-acting/background insulin [e.g., insulin glargine or insulin degludec]) in a patient with type 1 diabetes who presents with an acute illness or injury, unless being managed by an ongoing intravenous or subcutaneous insulin infusion.[293]

Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis (based on expert opinion).

Practical tip

Seek advice from a specialized inpatient diabetes team, if available, or endocrinology team if care is particularly complex (e.g., recurrent or severe hypoglycemia, persistent hyperglycemia or recurrent DKA), or your patient needs enteral feeding for a period of time. The diabetes team can also advise on the most appropriate insulin regimen and dosing during the hospital stay (based on expert opinion).

Noncritical illness

Generally, an insulin regimen is preferred for blood glucose management in individuals with diabetes receiving hospitalized care.[293]

If your patient is not eating or drinking or has poor oral intake, a subcutaneous basal insulin or basal plus bolus correction (every 6 hours) insulin plan is preferred.
If they are eating adequately, subcutaneous basal insulin with prandial (with each meal, up to 3-4 times a day) and correctional doses is preferred.

In a patient who is already managing their diabetes with insulin, consider whether there is any need to adjust insulin dose when they are admitted to the hospital.

If a patient with type 1 or type 2 diabetes is taking insulin, has good glycemic control, and has not got significant hyperglycemia on admission, it may be appropriate to reduce their routine dose of subcutaneous basal insulin by 20%, particularly if they are not eating as much as they would normally at home (based on expert opinion). Another factor to bear in mind is that hospital meals generally contain less carbohydrate than meals patients would have at home.
Conversely, patients who are acutely ill with an infection sometimes need more insulin.
Regular monitoring of blood glucose (at least four times daily) can help guide appropriate adjustments to insulin dosing.

If a patient with diabetes had been using a continuous subcutaneous insulin infusion (CSII) (insulin pump) prior to hospital admission:

Follow your hospital protocol and request a specialized inpatient diabetes team, if available, or endocrinology consult.
Safe continuation of an insulin pump during hospital admission has been advocated by several professional organizations.[293][372][373][374]
Key criteria for safe use include that:[293][375]
- The patient is medically stable, willing, and capable of self-management
- There are hospital staff available with the appropriate expertise and training and institutional guidelines in place
- There are no contraindications
- Staff are available to perform confirmatory point-of-care (POC) glucose measurements at least four times a day (based on expert opinion).

Generally, withhold noninsulin glucose-lowering medication if your patient had been taking any of these before admission, and switch to insulin.[293]

On rare occasions, it may be acceptable for a patient with type 2 diabetes to continue noninsulin glucose-lowering medications, such as a dipeptidyl peptidase-4 inhibitor.[372] Only consider this in a patient who is:
- Clinically stable with mild hyperglycemia
- Eating regularly
- Has no contraindications (based on expert opinion).
Be aware of the risk of euglycemic ketoacidosis in a patient who has been taking an SGLT2 inhibitor and becomes acutely ill, particularly if dehydrated or with infection, or undergoes major surgery.[370][371]
- Ensure SGLT2 inhibitors are stopped on admission.[371]
- SGLT2 inhibitors (e.g., dapagliflozin, canagliflozin, empagliflozin) reduce blood glucose reabsorption in the kidneys (independently of insulin metabolism of glucose).[376]
- They can mask underlying ketoacidosis as the patient may have a normal (or near normal) serum glucose level (euglycemic ketoacidosis).[371]
- If an SGLT2 inhibitor is continued during illness, for instance where it is being taken for its prognostic benefit for heart failure, be aware of the risk of euglycemic ketoacidosis.[377] Monitor ketone levels on a daily basis (based on expert opinion).
- Check blood ketones as urinary ketone measurement may be unreliable.

Critical illness

Consider starting a continuous intravenous insulin infusion in a critically ill patient with diabetes and manage in the intensive care unit.[293][294]

Use a validated protocol/order set for the continuous intravenous insulin infusion. This allows predefined adjustments to the insulin infusion rate according to blood glucose measurements and past and current insulin infusion rates, to avoid hypoglycemia.

If a continuous intravenous insulin infusion is started:

In practice, subcutaneous basal insulin is generally discontinued.
- However, there may be advantages to continuing subcutaneous basal insulin, and UK-based guidelines recommend this.[378]
  - Continuing the subcutaneous basal insulin reduces the risk of ketosis if the intravenous insulin infusion is accidentally interrupted (e.g., by cannula displacement or blockage) or switched off (e.g., during transfer of the patient) (based on expert opinion).
  - If continued, the usual dose of basal subcutaneous insulin should be decreased by 25% unless it is known that the basal dose is not likely to cause hypoglycemia when fasting (based on expert opinion).
Stop the patient’s usual rapid-acting and mixed insulins while on an intravenous insulin infusion.[378]
Use the continuous intravenous insulin infusion for as short a time as possible.[378]

Once ready to discontinue a continuous intravenous insulin infusion:

Follow an appropriate order set/transition protocol to switch to scheduled subcutaneous insulin.[293]
- This should include calculating the total daily dose of subcutaneous insulin needed, dividing into appropriate basal and bolus doses, monitoring and adjusting dose based on glucose monitoring, and having orders in place for potential hypoglycemic episodes (based on expert opinion).
Give subcutaneous basal insulin at least 2 hours before discontinuing the intravenous infusion to minimize rebound hyperglycemia.[293]
- Emerging data suggests that early administration of subcutaneous basal insulin alongside intravenous insulin infusion does not seem to increase the risk of hypoglycemia.[379][380]

Discharge

Start thinking about a discharge plan at the time of hospitalization or after stabilization (based on expert opinion). This should be structured, tailored to the individual.[293]

Provide inpatient diabetes self-management education, focusing on skills needed after discharge and ensure follow-up and support strategies are in place.
Arrange medication reconciliation:
- Make sure this includes a strategy for switching back to the brand of insulin your patient was on at the time of hospitalization, if appropriate and approved by insurance.
- If noninsulin glucose-lowering medications have been temporarily stopped but will be reinstated after discharge, consider switching back to the discharge medication regimen 1-2 days before discharge, if time allows.
Communicate promptly to the relevant outpatient healthcare professionals.
Always check blood glucose before discharge home.

– monitor and manage blood glucose during the hospital admission

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monitor and manage blood glucose during the hospital admission

Treatment recommended for ALL patients in selected patient group

Monitor blood glucose levels at least four times a day (every 4-6 hours, or if eating, pre-meal and before bedtime) in any acutely ill patient with diabetes mellitus.[293]

The risk of hypo- and hyperglycemia increases when a person with diabetes is admitted to the hospital acutely (based on expert opinion).
Even more frequent monitoring is needed after any episode of hyperglycemia or hypoglycemia and after any change in hypoglycemic medication (based on expert opinion). If a correction dose of insulin is given at bedtime, check blood glucose about 4 to 6 hours later (usually about 2 a.m.) (based on expert opinion).
If your patient is having surgery, the American Diabetes Association (ADA) recommends monitoring blood glucose at least every 2 to 4 hours while the individual is taking nothing by mouth (npo).[293]
Any patient on an intravenous insulin infusion needs more frequent capillary blood glucose measurements, ranging from every 30 minutes to every 2 hours.[293]

Practical tip

Be aware that the accuracy of point-of-care glucose meter results can be affected by factors such as hypotension, shock, edema, anemia/erythrocytosis, and several medications including vasopressors.[293][294] If your patient’s clinical status does not correlate with their glucose result, confirm the glucose level by ordering a clinical laboratory test.[293]

Decide on and monitor target blood glucose levels.

There is a general consensus among different guideline organizations on target blood glucose levels for people with diabetes in hospital.

For most critically ill patients, the ADA recommends a target range of 140 to 180 mg/dL (7.8 to 10.0 mmol/L) once insulin has been started for persistent hyperglycemia.[293]
- Stricter target ranges, such as 110 to 140 mg/dL (6.1 to 7.8 mmol/L), may be acceptable in select critically ill patients, but only if they can be achieved without significant hypoglycemia.[293]
For most noncritically ill patients, the ADA and the Endocrine Society recommend a target range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L) once insulin has been started for persistent hyperglycemia.[293][372]
- Less stringent goals are appropriate in some patients, for instance those with frailty and/or severe comorbidities. The ADA recommends the focus in these people should be on avoiding hypoglycemia and symptomatic hyperglycemia.[293]

Evidence: Blood glucose targets for critically ill patients with hyperglycemia

Evidence argues against very tight glucose control in critically ill patients (a mixed population with and without a history of diabetes).

Intensive care setting:
- A randomized controlled trial (RCT) of critically ill patients in a primarily surgical intensive care setting found lower patient mortality with tight glucose control, 80 to 110 mg/dL (4.4 to 6.1 mmol/L), compared with "conventional" more liberal glucose control.[381]
- However, a subsequent multicenter RCT in critically ill medical and surgical patients in other intensive care settings found increased mortality with tighter glucose control, possibly due to more frequent episodes of hypoglycemia.[382]
- In 2017, two network meta-analyses found no benefit in mortality with tight glycemic control when compared with less tight control (79.2 to <109.8 mg/dL [4.4 to <6.1 mmol/L] vs. 140.4 to <219.6 mg/dL [7.8 to <12.2 mmol/L] in one report; <110 to 144 mg/dL [<6.1 to 8.0 mmol/L] vs. 144 to >180 mg/dL [8.0 to >10.0 mmol/L] in the second report) but a significant increase in the risk of hypoglycemia.[383][384]

More info: Self-management of diabetes in hospital

Support your patient to self-manage their diabetes (including monitoring blood glucose and insulin dose adjustment and administration in those treated with insulin) during a hospital admission if it is safe, the patient is willing, and it conforms to local protocols and national guidelines.[293]

The ADA recommends that suitable candidates for self-managing their diabetes in the hospital include those who:[293]

Normally perform self-management at home
Have the necessary cognitive and physical skills while in hospital
Have adequate oral intake
Are proficient in carbohydrate estimation
Take multiple daily insulin injections or use insulin pumps
Have stable insulin requirements, and
Understand sick-day management.

The patient and hospital care team should review the decision on self-management on a daily basis.[293]

Inspect injection sites if your patient is on insulin injections at home (based on expert opinion).

Check for insulin lipodystrophy and reeducate on injection technique, if needed.

Continuous glucose monitoring

Consider continuing personal continuous glucose monitoring (CGM) for any individual who uses this wearable technology at home.[385] Consult with the inpatient diabetes team if available.[374]

Although not approved by the Food and Drug Administration (FDA), emergency use authorization was granted during the coronavirus disease 2019 (COVID-19) pandemic and several professional bodies suggest this may be useful if complying with institutional policies and safety regulations.[293][385][374][369]
Confirmatory point-of-care glucose measurements are still needed for assessment of hypoglycemia and to guide decisions on insulin dosing.[293]
Be aware that some concomitant medications, such as acetaminophen (above a certain dose), dopamine, heparin, vitamin C, and hydroxyurea, may result in inaccurate measurements by CGM devices.[385][369]

More info: Hyperglycemia during the ongoing hospital admission

Hyperglycemia in admitted patients, whether with known diabetes or not, is associated with adverse patient outcomes, including increased mortality.[386]

Act promptly to treat hyperglycemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
The ADA recommends starting insulin therapy for persistent hyperglycemia, defined as blood glucose ≥180 mg/dL (≥10.0 mmol/L) confirmed on two occasions within 24 hours.[293]

If your patient has DKA or HHS, consider the appropriate unit for management.

Indications for management in the intensive care unit (ICU) include:[371]
- Severe DKA or severe HHS
- Critical illness as the precipitating cause (e.g., sepsis, acute myocardial infarction, gastrointestinal bleeding)
- Altered mental status
- Another concurrent indication for ICU admission.
See Diabetic ketoacidosis or Hyperosmolar hyperglycemic state.

Patients who are usually managed with sodium-glucose cotransporter-2 (SGLT2) inhibitors before unplanned hospitalization should have beta-hydroxybutyrate or blood ketone measurements to exclude euglycemic ketoacidosis (based on expert opinion).

Be aware that the following interventions may be associated with hyperglycemia and may need to be reviewed:[387]

Corticosteroids
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., tacrolimus)
Protease inhibitors (e.g., ritonavir)
Artificial nutrition (parenteral or enteral).

Ask for a specialized inpatient diabetes team consult, if available, or endocrinology consult where hyperglycemia is difficult to control.

More info: Hypoglycemia during the ongoing hospital admission

Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycemic episodes.

Be aware that hypoglycemia may be induced by treatment of hyperglycemia/diabetes and should be promptly recognized and treated.[388]
- Follow your hospital plan on treatment, which usually involves provision of 15 g of fast-acting carbohydrates (oral or enteric juice or table sugar; intravenous dextrose). Check blood glucose 15 minutes after the treatment. If the blood glucose is not in a safe range (usually considered to be >90 mg/dL [>5.0 mmol/L]), repeat the treatment. If the oral and enteric route is not available, administer intravenous dextrose. If the patient has no intravenous access, administer glucagon (based on expert opinion). See Diabetic hypoglycemia.
Review and adapt your patient’s treatment plan to prevent recurrent episodes.[293]
Document any episodes of hypoglycemia in the electronic health record.[293]

Causes of hypoglycemia include:[293]

Inappropriate insulin dose or dose adjustment
Insulin or oral hypoglycemic medication error
Wrong timing of insulin in relation to meals
Inadequate follow-up of first episode of hypoglycemia
Patients eating less but taking the same amount of diabetes medication
Reduced appetite or vomiting
Unexpected interruption of enteral or parenteral feedings
Reduced infusion rate of intravenous dextrose
Delayed or missed blood glucose checks
Sudden reduction of corticosteroid dose
Altered ability of a patient to report symptoms
Recovery from an acute illness.

Consider intervening if the blood glucose falls below 110 mg/dL (6.1 mmol/L) if on insulin or on sulfonylureas.

These patients are at high risk of progressing to hypoglycemia.
Give carbohydrates for preventing and managing hypoglycemia.
Modify insulin doses to prevent glucose from going below the target for the patient.

Take steps to reduce the risk of hypoglycemia at night. Assuming your patient can swallow, they are likely to have a smaller evening meal in the hospital than at home.

In the absence of significant hyperglycemia, consider reducing the evening basal insulin by 20% on admission (based on expert opinion).
Remember that for many patients with very high insulin needs at home, the needs are often much lower in the hospital, presumably because of changes in diet.
Review the dose used during recent prior hospitalization(s) when deciding the starting dose of insulin (based on expert opinion).

More info: Management of patients with diabetes who are receiving end-of-life care

If a patient with diabetes is receiving end-of-life care:

Discuss with your patient and their family/caregivers and agree on the level of intensity of care.[293] Less stringent targets for blood glucose levels are appropriate.[369]
Stopping basal insulin in a person with type 1 diabetes can lead to dehydration, ketoacidosis, nausea, and associated vomiting; therefore, continuing basal insulin in such a person could be considered as a comfort care (based on expert opinion).
Prioritize quality of life and dignity over strict blood glucose and blood pressure management.[293]

– examine your patient’s feet

– check baseline kidney function and monitor closely

– baseline neurologic exam

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baseline neurologic exam

Treatment recommended for ALL patients in selected patient group

Perform a baseline neurologic exam at the earliest appropriate opportunity for any patient with a history of stroke.

A patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke.[392][393][394] This risk is even higher in anyone with a history of stroke.
- If there is a change in neurologic status during admission, repeat the neurologic exam to evaluate for a new acute stroke.
Ensure the right level of nursing care for the patient’s condition and ensure that clear orders are written for the patient’s functional and cognitive status (e.g. fall precautions, 1:1, soft restraints, assistance with activities of daily living (ADLs).
- A patient with a history of stroke has a higher risk of falls and injury.[395]

– baseline cognitive and delirium assessments with collateral history

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baseline cognitive and delirium assessments with collateral history

Treatment recommended for ALL patients in selected patient group

Do a baseline cognitive assessment at the earliest opportunity in any patient with a history of dementia.

Take a collateral history from family, friend, or caregiver to establish whether your patient's cognitive function is stable, gradually declining, or acutely declined.[396]
Check your patient’s level of alertness and orientation to time, place, and person, and corroborate with caregivers and review your patient’s prior medical records (based on expert opinion).
If time allows, a standardized cognitive assessment score is helpful for tracking clinical progress, and determining discharge needs (based on expert opinion).
Validated scoring tools for cognitive assessment include:
- The Mini-Cog Alzheimer's Association: Mini-Cog(TM) Opens in new window
- The Montreal Cognitive Assessment (MoCA)[397]
- The Saint Louis University Mental Status Examination (SLUMS). Saint Louis University: SLUMS Opens in new window
This score is often best interpreted alongside a functional assessment, usually performed by an occupational therapist and/or a physical therapist.
The score may not represent the person's usual baseline for cognition due to the impact of the acute condition and its treatment, but it is still good practice to record and repeat it when the person has recovered (based on expert opinion).

Practical tip

If your patient with dementia is an older adult, consider using the "Geriatric 5Ms" as a framework to ensure core areas of care, such as baseline cognitive function, are addressed. The 5Ms are:[364][398]

Mind (mentation, dementia, depression, and delirium)
Mobility (gait, balance, and falls prevention)
Medications (polypharmacy, deprescribing, optimal prescribing, and adverse medication effects and medication burden)
Multicomplexity (multimorbidity and complex psychosocial situations)
Matters Most to Me (each individual's health outcome goals and care preferences).

Assess for delirium whenever a patient with dementia presents with acute illness.

People living with dementia are at increased risk of delirium when they are admitted to the hospital and throughout their admission.[396][399]
Delirium is not the same as dementia. It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganized thinking, and altered levels of consciousness.[400]
Use a screening tool to detect probable delirium, taking the setting into account. Commonly used tools include:
- The Delirium Triage Screen (DTS), which may be rapidly administered in an emergency department setting and assesses arousal and attention. If positive, confirm with a more specific tool, such as the brief Confusion Assessment Method (bCAM).[396][401][402]
- The Confusion Assessment Method (CAM), if your patient is not in a critical care setting.[396][403][404]
- The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) if your patient is in a critical care setting, or in the recovery room after surgery.[399][405][406][407]

Practical tip

Depression can mimic delirium in older adults, particularly in patients with cognitive impairment or other comorbid medical conditions.[396]

Ask if your patient has a diagnosis of depression. If not, use a very brief screening test, such as the Patient Health Questionnaire-2 or Emergency Department Depression Screening Instrument to screen older adults for depression.
A positive screen for depression should prompt further questions, e.g., on suicidal thoughts.

Consider a multicomponent intervention to reduce the risk of delirium during a hospital admission in people with dementia, such as the Hospital Elder Life Program (HELP), or other multicomponent nonpharmacologic intervention.[408][409][410] Measures to reduce the risk of delirium may include:[396][402][411]

Helping with orientation; make sure patients have their own glasses and/or hearing aids
Getting patients mobilized as soon as possible
Controlling pain adequately
Keeping patients well hydrated and helping them to eat adequately
Monitoring and maintaining regular bowel and bladder function
Using supplemental oxygen as needed
Monitoring for and treating postoperative complications as soon as possible
Reviewing the patient's medications
- Identify and avoid medications that are high-risk for precipitating delirium, such as benzodiazepines, corticosteroids, and anticholinergics.[396][412]

Foster familiarity, e.g., consider facilitating the patient's usual caregiver to stay with the patient and bring in familiar objects from home.[396][402]

Practical tip

Dementia is a risk factor for postoperative delirium.[411][413]

Evaluate baseline cognition using a brief screening tool preoperatively.
Consider the most appropriate method of analgesia to reduce the risk of postoperative delirium.
Monitor for postoperative delirium using a validated screening instrument (e.g., CAM-Short Form).[414]

Evidence: Primary prevention of delirium in hospital using nonpharmacologic interventions

There is evidence that a nonpharmacologic approach reduces the risk of delirium in non-ICU patients in hospital.

A systematic review compared nonpharmacologic interventions designed to prevent delirium with usual care or active control in adults in a non-ICU hospital setting.[415]

Interventions were multicomponent or single components, targeted at a specific risk factor, such as disorientation or dehydration.
Meta-analysis of 14 studies on multicomponent interventions found a significant reduction in incident delirium compared with usual care (RR 0.57, 95% CI 0.46 to 0.71).
There is emerging evidence that multicomponent interventions may reduce hospital length of stay (MD -1.3 days, 95% CI -2.56 to -0.04 days), but there is significant heterogeneity between the studies.
There is little information specifically on people with dementia as this group was frequently excluded from trials despite their increased risk of developing delirium.

More info: Initial investigations for a patient with delirium

If your patient has delirium, check for and treat life-threatening causes:[396][411][416]

Hypoxia
Hypoglycemia
Hypotension
Sepsis
Drug intoxication or withdrawal, including alcohol withdrawal
Acute myocardial infarction

Although every evaluation should be tailored to the individual patient, most patients should receive:[396]

Complete blood count
Comprehensive metabolic panel
Point-of-care glucose
Urinalysis with culture
ECG

Additional tests that may be needed include (based on expert opinion):

Thyroid function tests
Folate and vitamin B12
C-reactive protein
Blood cultures (if bacteremia is suspected)
Chest x-ray

Consider whether your patient requires computed tomography (CT) of the brain.[396]

CT brain should be arranged if your patient has focal neurological deficits, head trauma, reduced level of consciousness, or has a history of fall.
CT brain should also be considered if your patient takes anticoagulants.
In practice, a patient in the hospital setting who has a change in mental status will usually receive a CT brain (based on expert opinion).

Check for and treat any reversible causes of delirium:[396][402][411][416]

Pain
Infection
Poor nutrition
Constipation
Dehydration
Medications
- Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, antipsychotics, corticosteroids, or anticholinergics
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)

More info: Management of a patient with delirium

Manage patients with delirium initially with nonpharmacologic treatment.[396][402][411]

Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and caregivers to visit the patient.
Use verbal and nonverbal techniques to de-escalate conflict and distress.

Where nonpharmacologic treatments are ineffective, and the patient is in emotional distress or considered a risk to themselves or others, a short-term (often only 1-2 days is required) antipsychotic may be considered at lowest effective dose, and only as a last resort.[396][412][417]

Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as possible.[412][417]
Be aware that the evidence on the efficacy of antipsychotics for delirium is inconclusive, and guidance regarding choice of antipsychotic varies.[396][402][411]
Antipsychotics should be used with caution in patients with a history of dementia as there is an increased risk of mortality in these patients[396][417]
- A systematic review of antipsychotics for delirium in hospitalized adults concluded that the evidence did not support routine use of haloperidol or atypical antipsychotics for this purpose[418]
- All antipsychotics have a warning that they are not approved for dementia-related psychosis.[396]
Haloperidol is contraindicated in patients with Parkinson disease or in patients with dementia with Lewy bodies.[407] Check for all contraindications.
Consider baseline ECG before starting any antipsychotic medication (based on expert opinion).

Provide the family/caregiver with information so they understand what is happening and how they can work together with the clinical team to help the patient get back to their usual self (based on expert opinion).

Document the diagnosis of delirium clearly (based on expert opinion).

Evidence: Risks and safe withdrawal of antipsychotics in older adults

Antipsychotics are associated with increased mortality in people with dementia.

Short-term antipsychotics may sometimes be needed in people with dementia without delirium to enable safe care. However, antipsychotics have various adverse effects in older adults and are associated with an increased risk of death in people with dementia.

A Cochrane review found very low certainty evidence that typical antipsychotics such as haloperidol improve agitation, but reported that they may improve psychosis slightly in people with Alzheimer disease and vascular dementia. Atypical antipsychotics probably reduce agitation. Both types increase the risk of somnolence and extrapyramidal symptoms.[419]
A network meta-analysis found that people who take atypical antipsychotics for behavioral and psychological symptoms of dementia may have a small improvement in behavioral and psychological symptoms but have increased safety risks including for cerebrovascular adverse events, compared with those taking placebo.[420]
Contrary to popular belief, long-term antipsychotic use can be safely withdrawn in most people with dementia once behavior has settled.[421]

Consider a psychiatric consult if your patient develops severe psychosis or agitation that is not responding to multicomponent interventions and antipsychotic medications (based on expert opinion).

suspected bacterial etiology (exacerbation of lesser severity)

Consider – narrow-spectrum antibiotic

Back

Consider –

narrow-spectrum antibiotic

Treatment recommended for SOME patients in selected patient group

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends antibiotics for patients with an acute exacerbation of COPD and an increase in sputum purulence, plus an increase in sputum volume and/or increased dyspnea.[1] The American Academy of Family Physicians (AAFP) guidelines, however, recommend antibiotics for all patients with acute exacerbations of COPD.[159]

It has been recommended that more narrow-spectrum antibiotics (e.g., amoxicillin, amoxicillin/clavulanate, azithromycin, doxycycline, second-generation cephalosporins, trimethoprim/sulfamethoxazole) be considered for patients at less risk for a poor outcome and with an exacerbation of lesser severity.[154] The severity depends on the patient's prior status and any changes to previous baseline investigation (based on symptoms, examination, lung function, ABG).[157]

Some patients with COPD may keep antibiotics at home for use in an exacerbation as part of their self-management plan.[157]

Patients who receive antibiotics are at increased risk for antibiotic-associated diarrhea, compared with placebo, although the difference is not statistically significant.[200] [ ]

Antibiotic choice and duration of therapy is an unresolved issue, but in general should be based on local resistance patterns and patient history and preferences, including any previous culture results for the patient.[1][154][159] The most common bacterial pathogens include: Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.[35][40]

It has been shown that short courses of antibiotics (e.g., 5 days) are equally effective as longer courses (e.g., >5 days) for patients with mild to moderate exacerbations of COPD.[201][202][203] When indicated, GOLD recommends that the duration of antibiotic therapy should be 5 to 7 days.[1] More recent guidance from the American College of Physicians recommends limiting antibiotic treatment to 5 days in patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection.[204]

Oral antibiotics should be given first-line if possible, and if the severity of the exacerbation does not necessitate intravenous antibiotics.[1][157] If the patient’s dyspnea and/or sputum purulence improve, this suggests that the antibiotic is effective.[1]

Antibiotic-resistant bacteria should be considered, and a sputum sample sent for microscopy, culture, and Gram stain if symptoms have not improved following antibiotic treatment, and if these tests have not been done already.[157]

Infectious disease consultation may be needed if symptoms do not improve after repeated courses of antibiotics, or with a bacterial infection resistant to oral antibiotics, or for patients who cannot take oral medications.[157]

Primary options

amoxicillin: 500 mg orally three times daily

amoxicillin : 500 mg orally three times daily

amoxicillin: 500 mg orally three times daily

doxycycline: 100 mg orally twice daily

doxycycline : 100 mg orally twice daily

doxycycline: 100 mg orally twice daily

sulfamethoxazole/trimethoprim: 160 mg orally twice daily

sulfamethoxazole/trimethoprim : 160 mg orally twice daily

sulfamethoxazole/trimethoprim: 160 mg orally twice daily

azithromycin: 500 mg orally once daily on day 1, followed by 250 mg once daily for 4 days

azithromycin : 500 mg orally once daily on day 1, followed by 250 mg once daily for 4 days

azithromycin: 500 mg orally once daily on day 1, followed by 250 mg once daily for 4 days

Secondary options

cefuroxime axetil: 250-500 mg orally twice daily

cefuroxime axetil : 250-500 mg orally twice daily

cefuroxime axetil: 250-500 mg orally twice daily

amoxicillin/clavulanate: 875 mg orally twice daily

amoxicillin/clavulanate : 875 mg orally twice daily

amoxicillin/clavulanate: 875 mg orally twice daily

clarithromycin: 500 mg orally twice daily

clarithromycin : 500 mg orally twice daily

clarithromycin: 500 mg orally twice daily

suspected bacterial etiology (exacerbation of greater severity)

Consider – broad-spectrum antibiotic

Back

Consider –

broad-spectrum antibiotic

Treatment recommended for SOME patients in selected patient group

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends antibiotics for patient with an acute exacerbation of COPD and an increase in sputum purulence, plus an increase in sputum volume, and/or increased dyspnea.[1]

GOLD also recommends that antibiotics should be given to patients with severe exacerbations requiring mechanical ventilation (invasive or noninvasive).[1] Patients with more severe exacerbations, particularly those requiring treatment in the intensive care unit (ICU), have been shown to derive greater benefit from antibiotic therapy.[80][200] [ ]

The American Academy of Family Physicians (AAFP) guidelines, however, recommend antibiotics for all patients with acute exacerbations of COPD.[159]

Some patients with COPD may keep antibiotics at home for use in an exacerbation as part of their self-management plan.[157]

Patients with more severe underlying COPD, and those with greater exacerbation severity, are more often colonized with gram-negative bacteria such as Pseudomonas aeruginosa or other enteric gram-negative organisms and/or Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus).[78] Therefore, broad-spectrum antibiotics such as ampicillin/sulbactam, piperacillin/tazobactam, vancomycin, and fluoroquinolones (e.g., ciprofloxacin, levofloxacin, or moxifloxacin) are considered for patients at greater risk for a poor outcome, or with an episode of greater severity.[78][154] Agents with activity against Pseudomonas aeruginosa are also indicated for people at risk of this infection.[40] The choice of antibiotic should also be based in part on local bacterial resistance patterns.

Sputum cultures or endotracheal aspirates (in patients who are intubated) are recommended for assessment of bacterial infection in patients with severe lung function impairment, those with a history of frequent exacerbations, and/or in patients hospitalized with COPD exacerbations or who require mechanical ventilation, as gram-negative bacteria (such as Pseudomonas species) or resistant pathogens may be present.[1][40] Consideration may also be given to obtaining a sputum culture in patients who have bronchiectasis and suspected infectious exacerbations as a feature of their COPD.

Risk factors for a poor outcome include recent history of antibiotic use, more severe baseline COPD, need for hospitalization, treatment failure, prior antibiotic resistance, or risk factors for healthcare-associated infections. Critically ill patients in the ICU are also at higher risk.[78]

Use of accessory muscles of respiration, paradoxical respirations, cyanosis, new peripheral edema, hemodynamic instability, and worsened mental status e.g., confusion, lethargy, coma) are important indicators of a more severe exacerbation.[1]

Patients who receive antibiotics are at increased risk for antibiotic-associated diarrhea, compared with placebo, although the difference is not statistically significant.[200] [ ]

Antibiotic choice and duration of therapy is an unresolved issue, but in general should be based on local resistance patterns and patient history and preferences including any previous culture results for the patient.[1][154][159] The most common bacterial pathogens include: Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.[35][40] When indicated, GOLD recommends that the duration of antibiotic therapy should be 5-7 days, but local guidelines should be consulted.[1] More recent guidance from the American College of Physicians recommends limiting antibiotic treatment to 5 days in patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection.[204] If the patient's dyspnea and/or sputum purulence improve, this suggests that the antibiotic is effective.[1] Guidelines from the National Institute for Health and Care Excellence (NICE) recommend that, if intravenous antibiotics are given, they should be reviewed within 48 hours and stepped down to oral antibiotics where possible.[157]

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[213] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.

Primary options

ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours

ampicillin/sulbactam : 1.5 to 3 g intravenously every 6 hours

ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours

piperacillin/tazobactam: 3.375 g intravenously every 6 hours

piperacillin/tazobactam : 3.375 g intravenously every 6 hours

piperacillin/tazobactam: 3.375 g intravenously every 6 hours

vancomycin: 500-1000 mg intravenously every 12 hours

vancomycin : 500-1000 mg intravenously every 12 hours

vancomycin: 500-1000 mg intravenously every 12 hours

Secondary options

levofloxacin: 500 mg orally/intravenously once daily

levofloxacin : 500 mg orally/intravenously once daily

levofloxacin: 500 mg orally/intravenously once daily

ciprofloxacin: 500-750 mg orally twice daily; 400 mg intravenously every 8-12 hours

ciprofloxacin : 500-750 mg orally twice daily; 400 mg intravenously every 8-12 hours

ciprofloxacin: 500-750 mg orally twice daily; 400 mg intravenously every 8-12 hours

moxifloxacin: 400 mg orally/intravenously once daily

moxifloxacin : 400 mg orally/intravenously once daily

moxifloxacin: 400 mg orally/intravenously once daily

respiratory insufficiency

Consider – noninvasive mechanical ventilation

Back

Consider –

noninvasive mechanical ventilation

Treatment recommended for SOME patients in selected patient group

Severity depends on the patient's prior status and any changes to previous baseline investigation (based on symptoms, examination, lung function, ABG). Use of accessory muscles of respiration, paradoxical respirations, cyanosis, new peripheral edema, hemodynamic instability, and worsened mental status (e.g., confusion, lethargy, coma) are important indicators of a more severe exacerbation.[1]

Respiratory failure is often seen in patients with severe acute exacerbations of COPD. Patients with severe exacerbations who do not appear to respond sufficiently to initial interventions should be considered for noninvasive mechanical ventilation (NIV). The use of NIV has been shown to improve gas exchange, reduce dyspnea, decrease the need for endotracheal intubation, reduce complications such as pneumonia, and decrease length of hospitalization and mortality in these patients.[1][117][214][215][216][217][218] [ ] [Evidence B] Where possible, NIV should be used in preference to invasive mechanical ventilation for respiratory failure associated with COPD exacerbation.

NIV use should be considered for patients with one or more of the following: respiratory acidosis (partial pressure of carbon dioxide [PaCO₂] ≥6.0 kPa or 45 mmHg and arterial pH ≤7.35); severe dyspnea with signs that suggest fatigue of respiratory muscles, or increased work of breathing, or both, such as the use of accessory muscles of respiration, paradoxical movement of the abdomen, or retraction of the intercostal spaces; persistent hypoxemia while on supplemental oxygen.[1]

Improvements in the patient's level of dyspnea and physiologic state are typically seen within 1 to 4 hours.[219] The Global Initiative for Chronic Obstructive Lung Disease report recommends that if patients improve and can breathe unassisted for at least 4 hours, then NIV can be stopped.[1]

However, NIV is not successful for all patients, and clinicians should discuss the risks and benefits of invasive mechanical ventilation with patients receiving NIV to determine their desired course of treatment.

Consider – invasive mechanical ventilation

Back

Consider –

invasive mechanical ventilation

Treatment recommended for SOME patients in selected patient group

Noninvasive mechanical ventilation (NIV) may fail. Invasive mechanical ventilation should be considered for patients with outright respiratory or cardiac arrest, who are in or have signs of impending acute respiratory failure despite NIV, have impaired mental status or cardiovascular instability, are at high risk for aspiration, or for whom NIV cannot be appropriately applied (e.g., craniofacial trauma, recent gastroesophageal surgery, copious secretions, anxiety disorder, facial discomfort, or severe skin breakdown).[220]

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Physiologic criteria for invasive mechanical ventilation include the following: life-threatening hypoxemia in patients unable to tolerate NIV, inability to tolerate NIV or failure of NIV, respiratory or cardiac arrest, irregular breathing with gasping or loss of consciousness, massive aspiration or persistent vomiting, inability to clear respiratory secretions, heart rate <50 beats per minute with diminished alertness, severe hemodynamic instability not responsive to medical treatment, or severe ventricular or supraventricular arrhythmias.[1][221]

The risk for mortality is significant (11% to 49%) for people with severe disease in whom invasive mechanical ventilation is indicated.[12][222] Complications of mechanical ventilation include ventilator-associated pneumonia and barotrauma.

Weaning patients with severe COPD from mechanical ventilation can be difficult.[220] Use of NIV to assist weaning from mechanical ventilation can reduce weaning failure and nosocomial pneumonia, and may reduce mortality.[223][224]

Establish goals of care, taking into account any advance directives

Ask your patient if they have an advance directive (e.g., a living will, a healthcare proxy) and/or a Do Not Resuscitate (DNR) or Do Not Intubate (DNI) order.[422] Health Quality & Safety Commission NZ: Shared goals of care principles for health service providers Opens in new window

In consultation with your patient (and/or their family or caregivers if applicable), establish goals of care for their acute medical concern, as well as life-sustaining treatment options and code status as early as possible (based on expert opinion).

This applies to all patients, but may be particularly relevant to patients living with frailty and/or with certain comorbidities, such as dementia, stroke, heart failure, COPD, and late-stage CKD (based on expert opinion).
Ensure any existing advance directives align with your patient's current preferences and goals of care.[422]

Practical tip

"Goals of care" are the overarching aims of medical care for a patient, taking into account the clinical context and the patient's values and priorities. Discussions about goals of care can be used to guide decisions on the use and limitations of specific treatments.[423]

Discuss specific treatment options and health trajectory to help your patient (or surrogate decision-maker) make informed decisions about their care.[422][424][425]

This should include ( based on expert opinion):
- Code status (e.g., Do Not Resuscitate [DNR] order, Do Not Intubate [DNI] order)
- Other life-sustaining treatment options (e.g., vasopressors, extracorporeal membrane oxygenation [ECMO], kidney replacement therapy, blood transfusions, parenteral/enteral nutrition).

Promote patient autonomy by establishing your patient's values and priorities, and discussing potential benefits and harms of treatments. This helps to align care decisions and avoid unwanted interventions.[425]

In some situations, a patient with dementia, other significant comorbidities, or learning disabilities (particularly if they are acutely ill) may lack the decision-making capacity to make certain care decisions.

Assess and document decision-making capacity (the ability to make a specific decision at the time that the decision needs to be made).[426][427][428]
If your patient lacks decision-making capacity, establish whether they have an advance directive.[424][427][428]
- This may include a living will and/or a designated proxy known as a Durable Power of Attorney for Healthcare (DPAHC).[427]
If your patient who lacks decision-making capacity has no applicable advance directive, including no designated proxy, identify a surrogate decision maker from a priority list of individuals such as spouse, adult child, and adult sibling.[427][428]
- The hierarchy of this list, and the scope of surrogates' decision-making, varies from state to state.
- Ensure a surrogate's decisions are consistent with patient preferences and best interests.
- In the case of conflict, consider consulting your hospital's ethics committees.
If your patient who lacks decision-making capacity is unrepresented/unbefriended, and in an urgent or life-threatening situation:[427][428]
- Use all available information on a patient's preferences, values, and beliefs to guide treatment decisions. If preferences are not known, urgent care decisions should be made in the patient's best interests.[424][427][429][430]
In a less urgent situation, rarely, a court-appointed guardian may be appointed to make decisions in this context.[424][427]

ONGOING

after stabilization

1st line – pulmonary rehabilitation and disease-management programs

Back

1st line –

pulmonary rehabilitation and disease-management programs

Patients with COPD who experience acute exacerbations of COPD often have skeletal muscle dysfunction, potentially due to limited physical activity, nutritional disturbances, corticosteroid use, and/or systemic inflammatory factors.[228][229]

A systematic review that included 13 randomized controlled trials reported reduced mortality and number of readmissions among patients who had pulmonary rehabilitation initiated during hospitalization or within 4 weeks of discharge. Long-term effects on mortality were not statistically significant, but improvements in health-related quality of life and exercise capacity appeared to be maintained for at least 12 months.[1][230] These results have been corroborated by real world evidence in which pulmonary rehabilitation within 90 days of discharge was significantly associated with a lower risk of mortality and fewer rehospitalizations at one year.[1][231][232]

Pulmonary rehabilitation is a multidisciplinary program of care that involves physical rehabilitation as well as guidance on disease management, nutrition, and other lifestyle issues (e.g., smoking cessation, medication adherence and inhaler technique, supplemental oxygen, and maintenance of physical activity).[233][234]

As COPD patients and their exacerbations are highly heterogeneous, determining who may benefit from respiratory rehabilitation varies greatly according to the comorbidities and other characteristics of each patient.

Selected forms of exercise rehabilitation initiated during a hospitalization for COPD exacerbation, including resistance strength training and transcutaneous electrical muscle stimulation, are well tolerated and can prevent muscle function decline and hasten functional status recovery.[235][236][237]

Pulmonary rehabilitation initiated early during the recovery phase of an exacerbation is safe and effective, and leads to improvements in exercise tolerance, physical abilities, the degree of symptoms due to COPD, and quality of life.[238][239][240][241][242][243][244][245]

Comprehensive supervised pulmonary rehabilitation in the outpatient setting in the post-exacerbation period also decreases the risk for future hospitalization.[234][241][242][246] Participation in pulmonary rehabilitation within 90 days of discharge following hospitalization for COPD exacerbation is associated with a significant decrease in mortality risk.[232] Unsupervised, home-based exercise training following exacerbations does not appear to confer the same benefits.[247]

Disease management programs can be helpful, but their use remains controversial given that a randomized controlled trial had to be stopped early due to a noted increase in mortality in the comprehensive care management group, as compared with control patients who were receiving guideline-based routine medical care.[233][248][249][250][251] Another study involving unsupervised home-based exercise training following hospitalization for acute COPD exacerbation also showed a mortality signal at the 6-month post-hospitalization time point.[247]

Some data is emerging that hospital-at-home care with support from respiratory nurses may be appropriate for selected people with moderate exacerbations of COPD.[252] [ ] However, this approach is not yet considered the standard of care, and people with unstable vital signs, decompensated gas exchange, acute respiratory acidosis, worsened hypoxemia, change in mental status, or significant comorbid illness are not suitable for this approach.[98][253]

A randomized controlled trial has suggested that the use of nurse-centered tele-assistance may decrease the occurrence of exacerbations of COPD and hospitalization. The use of such programs may be cost-saving.[254] However, another randomized controlled trial demonstrated that tele-monitoring integrated into existing clinical services did not reduce hospital admissions or improve patients’ quality of life.[255]

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Acute exacerbation of chronic obstructive pulmonary disease

Treatment algorithm

at presentation

short-acting bronchodilator

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

systemic corticosteroid

Manage your patient’s diabetes when they are taking corticosteroids

Monitor for psychiatric complications of corticosteroids

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

airway clearance techniques

oxygen

supportive care

Assess fluid status and manage fluid balance particularly closely

More info: The RUSH exam

Practical tip

Heart failure

CKD

Continue to monitor fluid balance particularly closely

Practical tip

De-escalation

Mental status exam

Consider psychiatric consult

Anticoagulation in your patient with CKD

Manage tobacco dependence

Practical tip

review current treatment for depression in your patient with COPD

Evidence: Psychological therapies for depression in people with COPD

Practical tip

take your patient's comorbidities and level of frailty into account when deciding on setting for care

Practical tip

withhold antihypertensives and/or diuretics if hypotensive

Plus – monitor comorbidities during hospital stay

monitor comorbidities during hospital stay

review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

Practical tip

Noncritical illness

Critical illness

Discharge

monitor and manage blood glucose during the hospital admission

Practical tip

Evidence: Blood glucose targets for critically ill patients with hyperglycemia

More info: Self-management of diabetes in hospital

More info: Hyperglycemia during the ongoing hospital admission

More info: Hypoglycemia during the ongoing hospital admission

More info: Management of patients with diabetes who are receiving end-of-life care

examine your patient’s feet

check baseline kidney function and monitor closely

baseline neurologic exam

baseline cognitive and delirium assessments with collateral history

Practical tip

Practical tip

Practical tip

Evidence: Primary prevention of delirium in hospital using nonpharmacologic interventions

More info: Initial investigations for a patient with delirium

More info: Management of a patient with delirium

Evidence: Risks and safe withdrawal of antipsychotics in older adults

suspected bacterial etiology (exacerbation of lesser severity)

narrow-spectrum antibiotic

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

suspected bacterial etiology (exacerbation of greater severity)

broad-spectrum antibiotic

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options