COPD Exacerbations: Home vs. Hospital Decision

Not every COPD flare needs admission. The right site of care comes from early risk signals, gas exchange, work of breathing, comorbidity load, and home support. Here’s a clean, evidence-oriented pathway.

Definition & First Principles

An exacerbation is an acute worsening of respiratory symptoms beyond normal day-to-day variation, leading to a change in therapy. Start by stabilizing ABCs, ruling out mimics (pneumonia, heart failure, PE, pneumothorax), and quantifying gas-exchange risk.

Home vs. Hospital: Decision Signals

• Admit / observe if any of: SpO₂ < 88% on room air or need for new oxygen; RR ≥ 24–28/min with increased work of breathing; pH ≤ 7.35 or rising PaCO₂; hemodynamic instability; altered mental status; pneumonia on imaging; high-risk comorbidities (CAD, heart failure, CKD); poor home support or inability to use inhalers/NIV.
• Home management is reasonable when: mild–moderate dyspnea; no red flags; SpO₂ ≥ 88–90% on baseline oxygen; good response to initial bronchodilators; reliable follow-up and support.

Immediate ED/Clinic Management

• Bronchodilators: Short-acting beta-agonist (SABA) ± short-acting muscarinic antagonist (SAMA) via MDI with spacer or nebulizer; repeat q20 min early if needed.
• Systemic steroids: Prednisone 40 mg PO daily for 5 days (or equivalent). IV route if unable to take PO.
• Oxygen: Titrate to SpO₂ 88–92% to avoid worsening hypercapnia; use Venturi mask if available for precise FiO₂.
• Antibiotics: Indicated with increased sputum purulence plus either volume or dyspnea, or if mechanical ventilation is required. Choices depend on local resistance and risk factors (e.g., amoxicillin-clavulanate, doxycycline, macrolide; cover Pseudomonas when appropriate).
• Non-invasive ventilation (NIV): Start early for acute hypercapnic respiratory failure—pH ≤ 7.35 and/or PaCO₂ elevated with dyspnea and accessory-muscle use. Escalate if worsening acidosis, hypoxemia, or intolerance.

Workup to Guide Site of Care

• Vitals & trend: HR, RR, BP, temperature, SpO₂ on baseline oxygen.
• ABG/VBG: pH and PaCO₂ (or PvCO₂ trend) if moderate–severe flare or poor response to therapy.
• CXR (or lung ultrasound) to assess pneumonia, pneumothorax, edema.
• Labs: CBC, basic metabolic panel; consider troponin/BNP if cardiac symptoms.

Discharge Criteria (Safe Home Plan)

• SpO₂ in the 88–92% target on baseline oxygen (or room air if normally not on oxygen).
• Improving dyspnea and work of breathing; stable vitals; able to use inhalers correctly.
• Clear home meds plan (see below), red-flag education, and a follow-up within 48–72 hours.

Home Medications & Short Course Plan

• Systemic steroid: Prednisone 40 mg daily × 5 days; no taper usually needed for short course.
• Bronchodilators: SABA q4–6h PRN; consider SAMA/SABA combo for 24–48h if symptomatic.
• Antibiotic (if indicated): 5–7 days based on local guidance and patient risk.
• Long-term control: Ensure correct maintenance inhaler (LABA/LAMA ± ICS) and technique; address adherence.

Preventing the Next Exacerbation

• Smoking cessation, vaccines (influenza, pneumococcal, COVID-19 as indicated), pulmonary rehab.
• Action plan: when to increase inhalers, when to start “rescue” steroids/antibiotics, and when to call.
• Address triggers—viral infections, pollutants, heart failure, undertreated OSA, medication lapses.

Red Flags (Escalate Now)

• SpO₂ < 88% despite oxygen; rising PaCO₂ with somnolence or confusion; pH ≤ 7.30; suspected pneumonia or pneumothorax; severe work of breathing; hemodynamic instability.

Patient FAQs

“Why not aim for 100% oxygen?” In COPD, too much oxygen can worsen CO₂ retention; 88–92% balances oxygenation and ventilation.

“Do I always need antibiotics?” Only if sputum purulence increases plus volume or dyspnea, or if you need ventilation.

References & Notes

Aligned with widely used COPD exacerbation pathways: early bronchodilation, short steroid course, targeted antibiotics when indicated, controlled oxygen, and NIV for hypercapnic failure. Local protocols vary—follow institutional guidance. Educational only.