A. Can Patient Use Metered Dose Inhaler (MDI) with Spacer Effectively? - The following are considerations for selection and dosing schedules for beta2-agonist: 

1. Beta2-adrenergic agonists are considered first-line agents in the treatment of acute exacerbation of COPD. Selective beta2-agonists should be used because they are less likely to cause tachycardia. An inhaled beta2-agonist can be given by nebulizer aerosolization or metered dose inhaler (MDI). Aerosolization using a low-volume nebulizer is generally the first mode used when the patient is severely dyspneic and can neither effectively breathe nor coordinate for effective MDI use. After the patient has stabilized and can use the MDI, there is no difference between using an MDI with a spacer compared with nebulized aerosolization.

2. Because few excellent placebo-controlled clinical trials have been conducted, an optimal dosing schedule of beta2-agonists cannot be suggested. However, beta2-agonists should be titrated to maximal effect when possible, monitoring closely for adverse effects of the larger-than-usual doses that are sometimes necessary to relieve airway obstruction. Beta2-agonists have a reduced functional half-life in exacerbation of COPD and therefore, if tolerated, may be given every 30 to 60 minutes under close supervision (including EKG monitoring). High-dose beta2- agonist treatment regimens have not been investigated widely in this patient population and should be used cautiously until results of more controlled clinical trails are available.

3. Bronchodilator Dosing (adapted and modified from American Thoracic Society guidelines)

1. Anticholinergic Therapy - An anticholinergic may be valuable as an additive agent or as a single agent, particularly if the patient is intolerant of beta2-agonist side effects. This may be especially important in patients with coronary artery disease or severe left ventricular dysfunction, in whom excessive tachycardia may have adverse sequelae. Higher-than-usual dosing of ipratroprium bromide, although possibly effective, has not been studied in patients with acute exacerbation of COPD. If the decision to use ipratropium is made, the following dose is suggested: 500 mg every 6 hours by nebulizer, or 6 to 8 puffs every 4 hours by MDI with spacer.

2. Theophylline Use - There is inadequate evidence in the literature to recommend the routine use of theophylline or aminophylline in the acute treatment of COPD exacerbation. However, there is also inadequate evidence to exclude a benefit for selected patients. Toxicity occurs frequently in hospitalized patients and is associated with a prolonged length of stay. Clinicians who choose to use this agent must be thoroughly familiar with its metabolism, drug interactions, and toxicity.

3. Other Parenteral Agents - The parenteral administration of terbutaline or epinephrine has a prompt effect but is accompanied by an increased risk for tachycardia and may be arrhythmogenic when compared with the inhaled route. Since an increased potential for myocardial ischemia is an unintended consequence of parenteral adrenergic use, it cannot be recommended in adult patients with COPD. This is a particular concern in veterans in whom cigarette use is a potent risk factor for both COPD and coronary artery disease. Terbutaline and epinephrine are not recommended.

4. Additional Therapies/Treatments/Considerations - The following measures lack adequate evidence to support their routine use in the management of AECOPD: directed coughing, chest physiotherapy, positive end-expiratory pressure, nasotracheal suctioning, systemic hydration beyond replacement to euvolumia, intermittent positive pressure breathing, bland aerosol therapy, or mucolytic therapy. Further research is indicated in these areas.

The nutritional status of the patient is another important consideration. Care must be exercised so that patients receive adequate and appropriate nutrition during their stay. Also, patients should be encouraged to mobilize as soon as is practical. When confined to bed, range of motion exercises should be performed. Consider deep vein thrombosis prophylaxis therapy.

F. Modify Treatment - If the patient is improving, consider:

• Decreasing the frequency of inhaled beta2-agonists to every 4 to 6 hours
• Switching to MDI with spacer
• Switching from parenteral to oral medication
• Titrating oxygen as per Oxygen Therapy Module B4

• Consider using an aerosol beta2-agonist if MDI cannot be used effectively
• Consider using IV steroids, antibiotics.
• Titrate oxygen using oxygen protocol.
• Consider comorbidities or other contributory causes of COPD and treat.
  
  
Optimal dosing schedules for beta2-agonists cannot be recommended based on excellent placebo-controlled clinical trials. However, beta2-agonists should be titrated to maximal effect when possible, monitoring closely for adverse effects of the larger-than-usual doses that are sometimes necessary to relieve airway obstruction. beta2-agonists have a reduced functional half-life in exacerbation of COPD and therefore, if tolerated, may be given every 30 to 60 minutes under close supervision (including EKG monitoring). High-dose beta2-agonist treatment regimens have not been investigated widely in this patient population and should be used cautiously until results of more controlled clinical trials are available.