Mount Carmel Health Partners Clinical Guidelines Chronic Obstructive Pulmonary Disease | Page 5

Pharmacological Treatment ( continued )
1. Bronchodilators
• Short-acting beta-2 agonist and/or ipratropium MDI with spacer or hand-held nebulizer as needed
• Consider adding a long-acting beta-2 agonist or antimuscarinic bronchodilator
2. Glucocorticosteroids
• Prednisone 40 mg orally daily for 5 days for non-critically ill patients, consider as the first line agent
• Consider using an inhaled corticosteroid in patients experiencing recurrent exacerbations
3. Antibiotics to be given to patients:
• With increased dyspnea, increased sputum volume, and increased sputum purulence ( must have 2 out 3 symptoms)
• Who require mechanical ventilation, pending sputum culture results
• Consider macrolide or doxycycline or bactrim
Antitussives Role of use inconclusive. Not recommended
Antibiotics Continuous use not recommended. Azithromycin (250 mg/day or 500 mg three times per week) or
erythromycin (500 mg BID) for one year in patients prone to exacerbations reduced risk of exacerbations.
Mucolytic agents Use is not recommended
Vasodilators & Immunoregulators Use is not recommended; May worsen oxygenation
Influenza vaccine Reduces illness and death in COPD patients by 50%; should be given yearly
Pneumococcal vaccine Individuals aged ≥65: PPSV23 (23-valent pneumococcal polysaccharide vaccine—Pneumovax 23) should be
given 6 to 12 months following administration of PCV-13 (pneumococcal conjugate vaccine 13—Prevar 13).
For patients who have previously received one or more doses of PPSV23, a single dose of PCV13 should be
given 1 or more years after the last PPSV23 dose was received.
Be sure that each patient's vaccinations are up to date and documented in the medical record.
Smoking Cessation Therapy
Nicotine replacement therapy is preferred option. Efficacy of e-cigarettes remains controversial for smoking
cessation. Varenicline, bupropion, and nortriptyline have shown increased long-term quit rates.
Oxygen Therapy
Long-term oxygen therapy increases survival, exercise tolerance, and cognitive performance in hypoxemic patients. This therapy can reverse
secondary polycythemia, prevent hypoxia, reverse hypoxia, decrease pulmonary artery pressure, and improve cardiac function.
Indications for initial oxygen therapy for Gold D COPD:
• PaO₂ is at or below 55mm Hg or SaO₂ is at or below 88% with or without hypercapnia confirmed twice over a three week period OR
• PaO₂ is between 55mm Hg and 60mm Hg or SaO₂ is 88%, and if there is evidence of pulmonary hypertension, peripheral edema
which suggests congestive heart failure, or polycythemia (hematocrit greater than 55%).
• Re-evaluate after 60-90 days with repeat arterial blood gas or SaO₂ to determine if oxygen is therapeutic or still indicated.
Following an Emergency Department Visit or Hospitalization:
• Schedule office visit within two weeks
• Evaluate symptoms and treatment regimen
• Assess need for oxygen therapy
• Review smoking status
• Evaluate inhaler technique
• Treat with inhaled corticosteroid if not on yet; consider treatment with phosphodiesterase-4 (PDE-4) inhibitor
• Consider referral to a pulmonologist for severe COPD despite optimal treatment to include:
◊ progressive FEV1 decline
◊ frequent exacerbations
◊ frequent emergency room visits and/or hospitalization
Potential Indications for Hospital Assessment of Admission
• Marked increase in intensity of symptoms, i.e., development of resting dyspnea
• Severe underlying COPD
• Onset of new physical signs (cyanosis, peripheral edema)
• Failure of exacerbation to respond to medical management
• Presence of serious comorbidities
• Frequent exacerbations
• Older age
• Insufficient home support
COPD - 5