Discharge Planning for Asthma and COPD Patients

Clinical Stability Criteria Before Discharge

The American Thoracic Society recommends that patients with asthma or COPD should only be discharged when they have been clinically stable on discharge medications for at least 24 hours, with peak expiratory flow >75% of predicted or best value, documented inhaler technique, a written self-management plan, and scheduled follow-up within one week 1, 2, 3
Peak expiratory flow (PEF) must be >75% of predicted or personal best value for asthma patients 1, 2, 3
PEF diurnal variability must be <25% for asthma patients 1, 2, 3
No nocturnal symptoms should be present for asthma patients 1, 2, 3
Respiratory rate <25 breaths/min and pulse <110 beats/min for asthma patients 1
Patient must have been stable on discharge medications for 24 hours minimum for asthma patients 1, 2, 4
Clinical improvement demonstrated after nebulized bronchodilator treatment for COPD patients 5
If oxygen was required, reassess need for long-term oxygen therapy (LTOT) before discharge for COPD patients 6, 7

The European Respiratory Society recommends prednisolone 30-60 mg daily for 1-3 weeks (or longer in chronic asthma cases) for asthma patients 2, 4
Inhaled corticosteroids at a higher dosage than before admission must be started at least 48 hours before discharge for asthma patients 2, 4
Short-acting β-agonist and/or ipratropium via MDI with spacer or hand-held nebulizer for COPD patients 6, 7
Prednisone 30-40 mg orally daily for 10-14 days for COPD patients 6, 7

Nebulizers must be replaced by standard inhaler devices 24-48 hours before discharge unless home nebulizer is required 5, 2, 4
Inhaler technique must be checked and documented in the medical record 1, 2, 3

Every patient must receive their own peak flow meter before discharge 1, 2, 3, 4
Patients must be taught how to use the meter correctly and interpret results 2, 3
A written action plan must specify exact PEF values at which to increase treatment, call their doctor, or return to hospital 2, 3, 4

Primary care physician visit within 1 week of discharge for asthma patients 1, 2, 3, 4
Respiratory physician appointment within 4 weeks for asthma patients 1, 2, 3, 4
Reassessment of oxygen requirements if started during hospitalization for COPD patients 6, 7

All asthma patients should receive pneumococcal vaccination before discharge as asthma is a high-risk condition 8
The 23-valent pneumococcal polysaccharide vaccine is recommended for adults with asthma at any age 8

Discharging before 24 hours on medications significantly increases relapse risk 3, 4
Failing to increase inhaled corticosteroid dose above pre-admission levels leads to treatment failure 3, 4
Not providing a written self-management plan is the single most preventable cause of readmission 3, 4
Continuing oxygen therapy without reassessing physiological need increases unnecessary costs without benefit for COPD patients 6, 7