Clinical pathway for acute exacerbations of chronic obstructive pulmonary disease: method development and five years of experience

Figures & data

Table 1 Therapeutic interventions included in the clinical pathway for the management of hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease

Frequency of the evaluations and testing: Blood tests, chest x-rays, and ABG analyses on the first, fourth, eighth, and 13th day of the exacerbation ABG analysis every morning if necessary Pulmonary function tests after inhalation of 200 μg salbutamol using an MDI with a spacer on the day after completion of the oral glucocorticosteroid course, or before discharge Pharmacological treatment: High-dose, frequent inhalation of a bronchodilator under supervision (introduce ➀ and change to ➁ in a few days) ➀ Repeated inhalation of 0.5 mL salbutamol using a nebulizer every hour ➁ Repeated inhalation of four puffs of salbutamol (400 μg) + four puffs of oxitropium bromide (400 μg) using an MDI and a spacer every 2 hours Oral administration of 0.5 mg/kg of prednisolone every morning for 10–14 days Antibiotics administration until the inflammatory markers disappear (cefazolin or piperacillin 1– 2 g × 2 div) Starting inhaled corticosteroids as maintenance therapy after the completion of systemic corticosteroid administration Respiratory management: Oxygen administration at the lowest concentration possible to maintain a PaO2 ≥ 60 mm Hg (start with a Ventimask^®) Start NPPV therapy if PaCO2 ≥ 45(−50) mm Hg or if pH drops to below 7.35, regardless of the oxygen concentration Pulmonary rehabilitation during the acute phase: Visit by a physical therapist and rehabilitation at an early stage Instructions on the methods of administration by a ward pharmacist In the case of breathing difficulties, a single dose of salbutamol by nebulizer, or 400 μg salbutamol and 400 μg oxitropium bromide by an MDI When changing to therapy using an MDI and a spacer to maintenance therapy including inhaled corticosteroids Inhalation techniques to be supervised by nurses following a standard checklist Planning for an early discharge Provision of a high-calorie diet and nutrition counseling when necessary

Abbreviations: ABG, arterial blood gas; MDI, metered-dose inhaler; NPPV, noninvasive positive pressure ventilation; PaCO₂, pressure of carbon dioxide in arterial blood; PaO₂, pressure of oxygen in arterial blood.

Table 2 Characteristics of a total of 276 episodes from 165 patients treated by the clinical pathway for acute exacerbations of chronic obstructive pulmonary disease

		Number	%
Gender	(Male)	234	84.8
Smoking condition	(Current)	51	18.5
Pneumonia as a complication	(Present)	83	30.1
Ambulance transportation	(Yes)	97	35.1
		Mean	Median	SD
Age	(years)	74.6	75.0	8.5
History of smoking	(pack-years)	71	59	40
Length of stay	(days)	20.3	15.0	18.9
Arterial blood gas before beginning treatment with variable concentration of oxygena
PaO2	(mm Hg)	64.5	58.5	29.4
PaCO2	(mm Hg)	47.4	40.4	18.4
Ph		7.397	7.419	0.082
Pulmonary function tests after treatmentb
FEV1	(L)	0.99	0.87	0.46
FEV1	(% predicted)	51.0	45.9	23.8
FEV1/FVC	(%)	44.4	41.3	14.3
FVC	(L)	2.24	2.15	0.73
FVC	(% predicted)	75.6	76.7	21.2
Barthel indexc	(score, 0–100)	60.1	65.0	31.3
6MWD before rehabilitationd	(meter)	199	175	143
6MWD after rehabilitatione	(meter)	268	270	140

a Notes: n = 275;

b n = 248;

c n = 245;

d n = 210;

e n = 210.

Abbreviations: 6MWD, 6-minute walk distance; FEV₁, forced expiratory volume in one second; FVC, forced vital capacity; PaCO₂, pressure of carbon dioxide in arterial blood; PaO₂, pressure of oxygen in arterial blood; SD, standard deviation.

Table 3 Outcomes of COPD-related hospitalizations during the study period

n = 300	The clinical pathway applied
	n = 11	Entry criteria violation
	n = 13	Disappearance of airflow limitation after discharge
	n = 45	Dropout
		n = 9	Died
		n = 7	Transferred to other long-term care facilities
		n = 29	Discharged to home from the hospital alive
	n = 231	Treatment with the clinical pathway completed
		n = 44	Without oxygen, without NPPV
		n = 122	With oxygen, without NPPV
		n = 110	With oxygen, with NPPV
n = 62	COPD-related hospitalizations outside the clinical pathway
	n = 25	AECOPD outside the clinical pathway
		n = 9	Intubations on the first day of exacerbation
		n = 1	Tracheotomy prior to the first day of exacerbation
		n = 3	Exacerbations due to pneumothorax
		n = 2	Exacerbations due to cardiac failure alone
		n = 10	Prompt discharge because of very mild exacerbations
	n = 37	Other reasons

Abbreviations: AECOPD, acute exacerbation of chronic obstructive pulmonary disease; COPD, chronic obstructive pulmonary disease; NPPV, noninvasive positive pressure ventilation.