1. Admit to:
2. Diagnosis: Exacerbation of COPD
3. Condition:
4. Vital Signs: q4h. Call physician if P >130; R >30, <10;
T >38.5°C; O2 Sat <90%.
5. Activity: Up as tolerated; bedside commode.
6. Nursing: Pulse oximeter. Measure peak flow with
portable peak flow meter bid and chart with vital signs.
No sedatives.
7. Diet: No added salt, no caffeine. Push fluids.
8. IV Fluids: D5 ½ NS with 20 mEq KCL/L at 125 cc/h.
9. Special Medications:
-Oxygen 1-2 L/min by NC or 24-35% by Venturi mask,keep O2 saturation 90-91%.
Beta-Agonists, Acute Treatment:
-Albuterol (Ventolin) 0.5 mg and ipratropium (Atrovent)0.5 mg in 2.5 mL NS q1-2h
until peak flow meter $200-250 L/min, then q4h OR
-Albuterol (Ventolin) MDI 2-4 puffs q4-6h.
-Albuterol/Ipratropium (Combivent) 2-4 puffs qid.
Corticosteroids and Anticholinergics:
-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h or 30-60 mg PO qd.
Followed by:
-Prednisone 20-60 mg PO qd.
-Triamcinolone (Azmacort) MDI 2 puffs qid or 4 puffs bid.
-Beclomethasone (Beclovent) MDI 4-8 puffs bid with spacer,
followed by gargling with water OR
-Flunisolide (AeroBid) MDI 2-4 puffs bid OR
-Ipratropium (Atrovent) MDI 2 puffs tid-qid OR
-Fluticasone (Flovent) 2-4 puffs bid (44 or 110mcg/puff.
Aminophylline and Theophylline (second line therapy):
-Aminophylline loading dose, 5.6 mg/kg total body weight over 20 min
(if not already on theophylline);then 0.5-0.6 mg/kg ideal body weight/hr
(500 mg in 250 mL of D5W); reduce if elderly, or heart or liver
disease (0.2-0.4 mg/kg/hr). Reduce loading to 50-75% if already taking
theophylline(1 mg/kg of aminophylline will raise levels by 2 mcg/mL) OR
-Theophylline IV solution loading dose, 4.5 mg/kg total body weight,
then 0.4-0.5 mg/kg ideal body weight/hr.
-Theophylline long acting (Theo-Dur) 100-400 mg PO bid-tid (3 mg/kg q8h);
80% of daily IV aminophylline in 2-3 doses.
Acute Bronchitis
-Ampicillin 1 gm IV q6h or 500 mg PO qid OR
-Trimethoprim/sulfamethoxazole (Septra DS) 160/800mg PO bid or 160/800 mg
IV q12h (10-15 mL in 100cc D5W tid) OR
-Cefuroxime (Zinacef) 750 mg IV q8h OR
-Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR
-Doxycycline (Vibra-tabs) 100 mg PO/IV bid
-Azithromycin (Zithromax) 500 mg x 1, then 250 mg PO qd x 4
or 500 mg IV q24h OR
-Clarithromycin (Biaxin) 250-500 mg PO bid OR
-Levofloxacin (Levaquin) 500 mg PO/IV qd [250, 500mg] OR
-Sparfloxacin (Zagam) 400 mg PO x 1, then 200 mg PO qd [200 mg].
10. Symptomatic Medications:
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Portable CXR, PFT's with bronchodilators,ECG,
impedance cardiography,echocardiogram.
12. Labs: ABG, CBC, SMA7, UA. Theophylline level stat and after
12-24h of infusion.Sputum Gram stain and C&S, alpha 1 antitrypsin level.
