COPD in the Hospital and the Transition Back to Home
A big concern for people with COPD is getting sick with a COPD flare-up and being admitted to the hospital.
It is possible to prevent some COPD flare-ups or exacerbations (x-saa-cer-bay-shuns), or at least catch them early so they don’t become serious. Doing this will help you avoid the need for a hospital stay.
However, even if you do all you can to prevent a COPD flare-up, you might still become sick enough to stay in the hospital overnight. This Guide will help you learn how to:
- Get the most out of a hospital stay and make it as helpful and painless as possible.
- Have an easier transition as you leave the hospital and return home so you can stay healthy and avoid future hospital stays as much as possible.
If You Need to Go to the Hospital, Always Bring:
- Up-to-date list of all your medicines including your inhaled breathing medications, over-the-counter meds, and dietary supplements
- List of your allergies, including medication allergies
- Name and contact number of someone you trust who could help with any decisions, if needed.
- Copy of your "living will" and/or medical power of attorney.
Health Care Professionals
When you’re in the hospital you might not be seen every day by your primary health care provider. It’s becoming more common that your hospital care is provided by a specialist called a “hospitalist provider.” These providers are doctors, nurse practitioners, or physician assistants who are trained in hospital treatments. It is their job to get you well and out of the hospital as soon as possible. They should be in touch with your primary care provider to make him/her aware of what is happening during your hospital stay. They should also inform your health care provider about the treatment and support you’ll need after you leave the hospital.
What to Expect in the Hospital
Emergency Department
A hospital stay often starts with a visit to the emergency department (ED). The ED is a busy place, helping people of all ages with a wide variety of problems ranging from issues with the lungs, heart, kidneys, stomach, brain, and more. Some patients in the ED may not be sick but are there because of an injury due to an accident.
You may have to wait a while until the doctor sees you. Be patient and understand that the doctors are probably helping somebody who is sicker than you are. Try to relax. You will get help.
The ED doctors, nurses, and others are specialists trained to treat patients with emergencies. Sometimes the ED staff can help you through the worst of your problem, get you started on treatment and send you home.
Rest
Your ED provider may decide that you have to stay overnight in the hospital. Even though you’ll be in bed, it can be hard to get enough rest. Health care professionals and other hospital workers come in and out of your room at all hours of the day and night. Try to rest as much as you can. Try to limit visitors who keep you awake when you really need to sleep. If you’re having trouble sleeping, tell your health care professionals. They might be able to help by limiting the number of times that staff wake you up, particularly
at night.
Treatment
While in the hospital, you will probably be treated by respiratory therapists. They are health care professionals who are experts in taking care of the lungs.
They may give you nebulizer treatments or inhalers with medicine that goes straight into your lungs. They may coach you to do deep breathing and encourage you to cough up mucus. They will then look at your mucus and record that information in your chart.
If your lungs are congested with mucus, respiratory therapists might perform chest physiotherapy (fizz ee oh thair ah pee). In this treatment, the therapist has you sit or lie down in a certain position and taps on your chest or back to shake the mucus loose. You may be given an airway clearance device to use. Using this device shakes the mucus loose with vibrations inside your bronchial airways.
Treatments may also include oxygen, antibiotics (an tee bye ah ticks), glucocorticosteroids (glue-coe-kort-te-coe-stair-royds) or fluids given by mouth or through an IV (a small tube in your vein). These treatments are almost always successful but there can be side effects.
Steroids can raise your blood pressure or blood sugar levels. Beta-agonist (fast-acting) bronchodilators (brawn-coe-die-lay-ters) may cause you to feel jittery. Anticholinergic (an-tee-coe-luh-nur jick) bronchodilators can lead to dry mouth and urinary problems. Antibiotics can lead to stomach and digestive problems. Overall, the goal is to help you breathe better, and if you have an infection, to get rid of it!
Make sure the hospitalist provider knows about the medicines you usually take at home. Most of these can be continued through your hospital stay.
Because you’re not moving around as much as usual, there may be a bigger chance of developing a blood clot. The hospitalist provider may order shots and/or special stockings for you to wear to decrease the chance of getting a blood clot. Your hospitalist provider may also prescribe medicines to decrease stomach acid and medicines to keep your bowels moving.
Intensive Care Unit (ICU) and the Step -Down Unit
If your COPD exacerbation is more serious, the hospitalist provider may decide to put you in a special unit with more nurses and closer monitoring. Intensive care units (ICUs) have specially trained nurses who are responsible for only a few patients at a time. There may also be a respiratory therapist who is assigned only to that unit.
In the ICU your heart, blood pressure, breathing rate, and oxygen will be monitored continually and you will be checked by health care professionals more often than in other areas of the hospital.
In a "step-down" unit you receive a middle level of care. You will have less monitoring and nursing care than in the ICU, but more than in a regular care hospital room.
More information from the American Thoracic Society experts: Managing The Intensive Care Unit (ICU) Experience: A Proactive Guide for Patients and Families May 2020
Helping You Breathe
Oxygen
Your health care provider will most likely prescribe supplemental oxygen. This will help you breathe easier and give your body the help it needs to get through the exacerbation.
Oxygen can be delivered to your lungs through a nasal cannula or through a variety of face masks, depending on how much oxygen you need. When you use oxygen in this way, you are still doing all the work of breathing. Respiratory therapists will help decide which form of oxygen delivery is best for the amount of extra oxygen you need.
When it’s time for discharge, be sure to ask if you need to make any adjustments to your home oxygen prescription. You will also need to make arrangements for a family member or caregiver to bring your portable oxygen to the hospital for you to use on your way home.
Non -Invasive Ventilation
If breathing is very difficult and does not get better with routine treatment, your hospitalist provider may suggest non-invasive ventilation (ven-ti-lay-shun). Non-invasive means that no tubes or needles are put into your body. This is often called Bi-PAP or CPAP. With this type of breathing device, a soft, snug mask is placed over your mouth or nose. It is connected to a machine that pushes air into your lungs. It can give you the help you need to get better, faster.
Sometimes your primary care provider may suggest you use a set up like this at home while you sleep. This may help if you have both COPD and sleep apnea (app-knee-ah). Sleep apnea is when you stop breathing for too long, too often, or when your breathing is too shallow while you sleep.
Ventilation
Sometimes you may be working so hard to breathe, yet you’re not breathing well enough to support your body – or your life. Your hospitalist provider may then decide that you need mechanical ventilation. This involves intubation (in-too-bay-shun), putting a tube through your nose or mouth and directly into your lungs. The tube is then connected to a machine called a ventilator, sometimes called a respirator.
This machine can do all or some of the breathing for you, helping you to rest from working so hard to breathe. This way your body is under less stress and the treatments you’re getting have a better chance of working to help you get better, faster.
It is important to understand that this kind of breathing support is done only if absolutely necessary, and only if you or your surrogate agrees to it. The hospitalist provider would give you medicine to help you relax and sleep while the ventilator helps you breathe.
In most cases the ventilator is temporary. The breathing tube can usually be removed within a few days. While this breathing tube is in place, you will not be able to talk or eat. During this time a small tube may be placed through your nose into your stomach so you can get the nutrition and medicines you need.
Longer Term Ventilation
If you are taking longer to recover, a decision may be made to take the tube out of your nose or mouth, and put a tube in through your neck. This is called a tracheostomy (tray-key-os-toh-mee). It is not painful and often more comfortable than a breathing tube in the nose or mouth. It can be easier for respiratory therapists and nurses to remove any mucus through this tube. At times you can even talk and eat with this tube in place. The tracheostomy tube is often temporary. It can be taken out once you are well enough to breathe on your own, and the opening in your neck will heal and close.
Ventilator Risks
Being on a ventilator has some risks. One is called “ventilator-associated pneumonia (new-moan-ya)” or VAP. This means you could get pneumonia while on the breathing machine. VAP can be harder to treat than other pneumonias, requiring powerful antibiotics. Hospitals now have strict programs in place to decrease the chance of patients getting these pneumonias. These programs have been very successful in preventing VAP.
Making Your Own Decisions
It is important to remember that most COPD flare-ups can be easily treated outside the hospital. Only a small fraction of people with COPD who have to stay overnight in the hospital have to be put on a ventilator. Most patients recover, come off the ventilator and go back home.
However, with severe COPD it’s harder to get better. In these severe cases, it might not help to be hooked up to a machine. Simple comfort care may be the best choice.
Other Hospital Stays for People with COPD
Like anybody else, people with COPD may need surgery. There are always risks with surgery, and they are not much worse in people with mild or moderate COPD. For people with severe COPD, however, surgery is more risky, especially when operating on the belly or chest.
Ask your health care professional to work with the surgery team to find the safest way to help you sleep during surgery and control your pain as you recover. Planning ahead and working as a team can make surgery safer for most people with COPD, even those with severe or very severe COPD.
Discharge from the Hospital
When you are told you are able to leave the hospital, you may be happy and eager to get going. However, before you leave is the best time to ask questions! This will help you know what to expect and how you can continue with a recovery that lasts.
Before You Leave the Hospital
Ask you hospitalist provider:
- (If you are a smoker) How can I quit? Can you provide medications to help with nicotine cravings both in the hospital and when I leave?
- Will the medicines I take when I go home be the same as those I was on before I came to the hospital?
- If not, why not?
- If not, will I eventually go back to my old medication
routine?
- Can you help me make sure I have enough of my medications until I can get to a pharmacy?
- Will a nurse or respiratory therapist come to my home? If
not, can the doctor order this?
- Can I be referred to pulmonary rehab?
- I’m already enrolled in pulmonary rehab, when can I go back?
- Can a physical therapist work with me at home until I regain
strength?
- When should I see my primary care provider for a follow-up appointment?
- What early signs should I watch for so I don’t get so sick again?
Ask your respiratory therapist:
- Are there special breathing techniques I can use?
- What’s the best way for me to use my inhalers? Will you watch me use them and tell me if I’m doing it right?
- What’s the best way for me to use my airway clearance device? Will you watch how I do it and tell me if I’m doing it right?
- Is there a breathing support group I can join?
Ask your nurse or social worker:
- (If you are having trouble paying for your medications) Can I get help paying for my medications?
- Can a nurse come and check on me at home?
- Do I need medical equipment such as a walker, wheelchair, shower chair or other devices?
- Can I get Meals-On-Wheels?
- Are there other services in my community that can help me adjust to being at home again?
If You Are Not Discharged to Your Home
Don’t be discouraged if you’re not able to go from the hospital directly to your home. You might not be strong enough to go home right away, so you may go to another place for a short time to get the care you need. There, you may have physical therapy to build your strength or get other treatment as you recover. The goal is to make sure you return home prepared to manage your COPD so you can stay healthy and independent.
Someone from the health care team will ask you where you would like to go. It is important to make your decision based on the information they can provide to you.
Ask if there are respiratory therapists on staff and if there are programs for patients with lung disease.
Going Home
Medications
It is important when you are discharged from the hospital that you go home on the right COPD controller / maintenance medicines (these are the breathing medicines that keep your lungs from flaring up and getting tight). This may be the same treatment you were on before you entered the hospital or it could be different.
Additional medicines may be added to make it less likely that you will have to go into the hospital again. The goal is to give you the least amount of medication while keeping your lungs as open as possible. This keeps your COPD under control with the lowest risk of side effects caused by the medicines. It is important to use the best technique possible when taking your inhalers to get as much medicine into your lungs as you can.
Be sure you understand why you have to keep on taking your antibiotics until they’re all gone, even if you’re feeling much better! If your health care provider orders steroid pills for you to take at home, make sure you understand the schedule for tapering down these steroids.
Oxygen
If you were not on oxygen before you went into the hospital, but will be on it after you go home, it might only be for a short time.
Once you have recovered, you might not need it anymore. On the other hand, if your health care provider says you need to use oxygen from now on, don’t worry. If you need it, using it as directed will help you feel better, be more active, and stay healthier.
Oxygen use for more than 16 hours per day is one of the few therapies proven to help people with COPD live longer. If it is prescribed, it will improve the function of your heart and blood vessels. Oxygen therapy also provides extra oxygen to your muscles when they need it most, during activities and exercise.
It takes some time to get used to living with supplemental oxygen, but by knowing how much it helps, you can learn to live with it. There are options for home oxygen systems. If yours is too heavy, ask your homecare company if there is a lighter system available. The use of an inexpensive finger-tip pulse oximeter will help you make sure your oxygen level is adequate. Check with your health care provider for permission to increase your oxygen flow if needed during activity or exercise. Remember – oxygen is a medicine. You should not adjust the settings or quit using it unless your health care provider has told you to do so.
Preventing Hospital Stays
Remember, it is often possible to avoid having to go into the hospital due to an exacerbation of COPD. It helps to watch for early warning signs and then do something about them!
Make sure your friends and family members are aware of these early warning signs. See Avoiding COPD Exacerbations to learn more about these warning signs.
Follow Up Appointment:
Make an appointment to see your primary care provider within two weeks of leaving the hospital. It is also important to schedule a follow-up appointment with a pulmonologist or a doctor who specializes in COPD.
Getting Back to Your Life with Optimal Care
After staying in the hospital, don’t expect to go home, be active, and feel good right away. It takes time to build your strength and get back to your life. Practicing optimal care for COPD will help you. Another great way to do this is to enroll in pulmonary rehabilitation. Ask your primary health care provider if pulmonary rehab is right for you.