NHS Forth Valley
6.2
Management of
Chronic Obstructive Pulmonary Disease
Management of Acute Exacerbations of COPD
1. Definition of Acute Exacerbation of COPD
A worsening of symptoms that is beyond normal day-to-day variation is acute in
onset and is sufficient to warrant a change in therapy. Causes of exacerbations can
be both infective and non-infective. The most common causes of an exacerbation are
infection and air pollution but in a third of exacerbations no cause can be identified.
2. Signs and Symptoms of Acute Exacerbation of COPD
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Increased breathlessness
Increased wheeziness
Chest tightness
Increased cough
Increased sputum purulence
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Increased sputum volume
Fluid retention
Decreased exercise tolerance
Increased fatigue
Acute confusion
• Uncommonly fever
3. Differential Diagnosis
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Pneumonia
Pneumothorax
Left Ventricular Failure/Pulmonary Oedema
Pulmonary Embolisim
Lung Cancer
4. Severity Assessment
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Increased dyspnoea
Tachypnoea
Pursed lip breathing
Use of accessory muscles and/or intercostal indrawing at rest
Lung Cancer
Acute confusion
New onset or worsening cyanosis
New onset or worsening of peripheral oedema
Reduced ability in activities of daily living
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• Upper airway obstruction
• Pleural effusion
• Recurrent aspiration
5. Need for Hospital Admission – Factors to consider
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Not able to cope at home
Severe breathlessness
Poor or deteriorating general condition
Poor activity level or confined to bed
Cyanosis
New onset or worsening peripheral oedema
Impaired conscious level
On long term oxygen therapy
Living alone and not coping
Acute confusion
Rapid onset
Significant co-morbidity, particularly: cardiac;
diabetes mellitus on insulin; pneumonia
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SaO2 < 90%
H+ >45
PaO2 <7kPa
Age
Diagnostic uncertainty
Newly occurring arrhythmias
Inability to eat or sleep due to symptoms
Visits to A&E in past 7 days
Previous relapse rate
Already on antibiotics or prednisolone
● Inadequate response to out-patient
management
6. Investigations to consider
The diagnosis of an exacerbation is made clinically
Primary Care
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Sputum culture in primary care is of very limited value because empirical therapy
is effective and should be prescribed promptly if the sputum is purulent.
Pulse oximetry should be measured where available and compared with the
patient’s known SaO2 when well.
Secondary Care
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Chest x-ray
SaO2 - note FiO2 (Mask %, Nasal cannulae flow rate)
ABG - note FiO2 (Mask %, Nasal cannulae flow rate)
ECG
FBC
U+E / glucose
Theophylline level if appropriate
Sputum MC & S if purulent
BCs if pyrexial-T > 37 0 C
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7. Treatment
Hospital at home should be considered but no firm recommendations can be made
about which patients are suitable. This depends on severity factors and patients’
preferences.
Primary Care
Bronchodilators
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Initiate or optimise bronchodilator treatment
o prn or regular short-acting β2 agonist + /o Regular short or long acting anticholinergic + /o Regular long acting β2 agonist
Check inhaler technique
Consider spacer device
Consider nebuliser, particularly if patient too breathless to inspire slowly or breath
– hold when using inhaler
Change to handheld inhaler as soon as condition improves.
Corticosteroids – oral
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Prednisolone 30-40mg once daily in the morning for 7 - 14 days*.
o Has been shown to be associated with a shorter recovery time
o There is no added benefit in increasing the course length beyond 14
days
o Monitor BMs in diabetic patients closely whilst on oral steroids and
maintain tight BM control
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If maintenance steroid currently or within the past year or frequent courses of
steroid reduce slowly to appropriate maintenance level.
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Consider osteoporosis prophylaxis for patients on maintenance therapy or
those receiving frequent courses. (See Forth Valley Osteoporosis Guideline)
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Patients must be made aware of course length and dose reduction and if
applicable, the adverse affects associated with prolonged therapy.
Antibiotic
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Treat exacerbation promptly with an antibiotic if sputum purulent
o First line - Amoxicillin 500mg tds for 5 days or
o If penicillin allergic - Doxycycline 200mg on first day, then 100mg
daily for 4 more days or Clarithromycin 500mg bd for 5 days.
o If risk factors for resistance (include co-morbid disease, severe COPD,
frequent exacerbations, antibiotics in last 3 months) or if patient has
failed on previous therapy - Co-amoxiclav 625mgs tds for 5 days. If
penicillin allergic discuss with microbiology.
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Chest Physiotherapy
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May be helpful in patients with excessive sputum production.
Smoking Cessation
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Encourage patient to stop smoking and refer to Smoking Cessation Service if
patient agrees.
Diuretic
Oral furosemide if indicated
Nutrition
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Consider supplements if patient too dyspnoeic to eat.
Counsel Patient on the following points:
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Prompt treatment of infection – recognition of an exacerbation
Annual influenza vaccination
One – off pneumococcal vaccination if not given previously.
Secondary Care
Monitoring
• Regular clinical assessment and observation of functional capacity.
• NEWS (National Early Warning Score)- includes HR, BP, T, RR
• Pulse oximetry (Type 1 respiratory failure)
• Repeat ABGs after any deterioration in patient or 60 minutes after any change in
treatment in Type II respiratory failure
• PEF pre and post nebulisers for 48 hours – stop if no improvement
• Daily K+
Bronchodilators – via nebuliser
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Combivent ® neb qds + salbutamol neb 2.5mg prn
or, if not responding:
Salbutamol neb 5mg qds + ipratropium neb 500mcg qds + salbutamol neb 2.55mg prn
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Driving Gas – must be specified on prescription:
O2 6-8 l/min UNLESS patient is hypercapnoeic when nebuliser must be driven by
a compressor with supplemental O2 administered simultaneously via nasal
cannulae at an appropriate flow rate (1l/min approximates to 24%, 2l/min to 28%,
3l/min to 35%, 4l/min to 40%)
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Oxygen Therapy – must be prescribed on Oxygen chart
Initially controlled use in patients with Type II Respiratory Failure (PaO2 < 8 kPa,
pCO2 > 6 kPa) – 24 - 28% venturi mask (more accurate) or 1-2l/min via nasal
cannulae. Measure ABGs 30 minutes later, and after any deterioration, and to
monitor recovery.
Aim: SaO2 94 – 98% in Type 1 Respiratory Failure (PaO2 < 8 kPa, pCO2 ≤ 6 kPa)
SaO2 88 – 92% in Type II Respiratory Failure (PaO2 < 8 kPa, pCO2 > 6k Pa)
Please note: SaO2 gives no indication of H+ or PaCO2
NHS Forth Valley Guidelines for Oxygen Treatment:
http://www.nhsforthvalley.com/__documents/qi/CE_Guideline_Respiratory/4Guidelin
esforOxygenTreatment.pdf
Systemic Corticosteroids
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Prednisolone 40mg once daily in the morning orally for 7 - 14 days in all hospital
treated patients
Hydrocortisone 50mg qds IV may be required to bypass the GI tract if patient
hypoxic or oedematous or if oral steroid cannot be taken or tolerated. This should
be changed to oral as soon as patient’s condition allows.
Check BM once daily in all patients and four times daily in diabetic patients
and maintain tight control of blood sugars.
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If maintenance steroid currently or within the past year or frequent courses of
steroid, reduce slowly to appropriate maintenance level.
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Consider osteoporosis prophylaxis for patients on maintenance therapy or those
receiving frequent courses. (Link to Forth Valley Osteoporosis Guideline)
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Patients must be made aware of course length and dose reduction and if
applicable, the adverse affects associated with prolonged therapy.
Antibiotic
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Treat exacerbation promptly with an antibiotic if sputum purulent.
o First line - Amoxicillin 500mg tds for 5 days or 2nd line - Co-amoxiclav
625mg tds if patient had course of Amoxicillin for current episode or
Doxycycline 200mg on first day, then 100mg daily for 4 more days if
patient has failed on previous therapy.
o If penicillin allergic - First line - Clarithromycin 500mg bd for 5 days
or 2nd line - Doxycycline 200mg on first day, then 100mg daily for 4
more days or Moxifloxacin 400mg daily for 5 days if patient has failed
on previous therapy.
o For patients who have been adequately treated in the community go
directly to 2nd line therapy.
IV therapy may be required to bypass GI tract in the hypoxic or oedematous patient
or if oral antibiotic cannot be taken or tolerated.
Check sensitivities with sputum culture when available.
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Intravenous aminophylline
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The use of intravenous aminophylline in the treatment of COPD exacerbations is
controversial but may provide additional bronchodilation and may increase
respiratory drive and respiratory muscle strength. It should only be used if there is
an inadequate response to nebulised bronchodilators and with appropriate
monitoring.
See NHS Forth Valley Guideline on the Management of Asthma:
‘Management of Acute Adult Asthma in Hospital’ for advice on dosing and
administration.
If you are viewing a hard copy of this document, the above guidance can be
downloaded via the Asthma pages on the Quality Improvement intranet site:
http://www.qifv.scot.nhs.uk/CE_TopicPage.asp?topic=Asthma
Chest Physiotherapy
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Arrange for help with sputum expectoration, breathing exercises and relaxation,
mobility and rehabilitation. May also be helpful if chest x-ray shows lobar
atelectasis. There is no evidence to support the use of nebulised saline in those
already on nebulised bronchodilators.
Smoking Cessation
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Encourage patient to stop smoking and refer to Smoking Cessation Service if
patient agrees
Diuretic
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Oral or IV furosemide if peripheral oedema – IV therapy may be required to
bypass the GI tract in the hypoxic or oedematous patient or if oral diuretic cannot
be taken or tolerated.
o Fluid balance chart
o Daily weight
o Fluid restriction – 1.5l/day
o No added salt diet
Ace Inhibitors
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There is no evidence to support the use of ACE Inhibitors
Thromboprophylaxis
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Ensure patients are prescribed appropriate thromboprophylaxis
o Enoxaparin 40mg s.c. once daily (20mg if CrCl < 30ml/min) or
o CrCl (ml/min)=(140-age) x weight(kg))/serum creatinine (μmol/l) (multiply
by 1.23 if male and 1.04 if female)
o TED Stockings
Nutrition
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Involve Dietitian if under weight in particular, but also if overweight, or if failing to
maintain adequate nutrition.
Fluids
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Assess fluid balance and prescribe if necessary.
Remember increased insensible losses due to tachypnoea, fever and reduced
ability to maintain oral intake.
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NIPPV
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In Type II respiratory failure if H+ remains > 45 despite 1hour of maximal
treatment – consider BiPAP
make clear plan in the event of further deterioration
Refer to BiPAP protocol.
NHS Forth Valley BIPAP Quick Reference Guide:
http://www.nhsforthvalley.com/__documents/qi/CE_Guideline_Respiratory/QRGForBI
PAP.pdf
NHS Forth Valley BIPAP Guideline:
http://www.nhsforthvalley.com/__documents/qi/CE_Guideline_Respiratory/BIPAP.pdf
Respiratory Stimulants
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Doxapram is only indicated for Type II respiratory failure where H+ > 45 when
NIPPV or IPPV is considered inappropriate.
o Dose: start at 1 mg/min – adjust according to response and ABGs.
Maximum useful dose not usually greater than 2 mg/min although can go
up to 4 mg/min maximum
IPPV
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Consider pre-morbid quality of life and functional status, oxygen requirements
when stable, co-morbidities and previous ITU admissions along with age, FEV1,
BMI, and patient’s wishes if known.
COPD Alert Card
• All patients with Type II respiratory failure should be issued with a COPD alert
card on discharge from hospital. These are supplied by the respiratory nurses
and signed by the respiratory physician.
Early Supported Discharge
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Refer all COPD patients to the Respiratory Specialist Nurses on admission.
Criteria for early supported discharge:
• Confirmed diagnosis of COPD
• No acute respiratory acidosis pH >7.35 or H+<45
• Alert and orientated
• No impairement of consciousness level
• No new focal abnormality on CXR
• O2 sats >88%
• Ability to cope at home, ADLs, able to cope with oxygen or
nebulisers
• No complicating co-morbidities
The respiratory nursing team can be contacted on ext 66618 or page 1966
• Following referral the respiratory nurse will assess the patient and confirm that
patient is suitable for early supported discharge. If the assessment proves the
patient is unsuitable the reason will be documented in patient’s notes.
• Arrangements can be made for the short term use of nebulisers and /or oxygen
(If oxygen is required discharge may not be secured that day).
• Following discharge short term community follow up will continue.
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Criteria for Unsupported Discharge
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Inhaled β2 agonist required no more frequently than every 4 hours.
Able to eat and sleep without frequent awakenings due to breathlessness.
Clinically stable for 12-24 hours.
SaO2 stable for 12-24 hours and satisfactory for that patient.
Patient returning to previous ambulatory function.
Off i.v. therapy for 12-24 hours.
Ensure patient/family/staff are confident that the patient can manage successfully
– OT assessment if in doubt.
Discharge Planning
Switch back to inhaled therapy once clinically stable unless usually on a home
nebuliser or is being considered for supported discharge by the Respiratory Nurses.
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Optimise usual maintenance bronchodilator therapy. (Unless patient identified as
suitable for supported discharge).
Check inhaler technique
Consider inhaled corticosteroid / long acting β2 agonist / Tiotropium
Give Tiotropium at night if early morning symptoms.
Do not give Combivent® or Ipratropium with Tiotropium – risk of urinary retention
in particular.
Theophylline – see chronic management.
There is no evidence to support the use of leukotriene receptor antagonists in
COPD
Arrange spirometry and transfer factor, if not done previously, and SaO2 predischarge – ABG if SaO2 on air < 92%
The respiratory nurses will complete the discharge check list below:
COPD Nurse Review
Name
. Date (time)
Suitable for early supported discharge Y / N
Estimated date of early supported discharge
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(if no detail below)
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Home nebulisers Y / N Home oxygen Y / N cylinders/concentrator
Maintenance steroids at home Y / N FEV1% (If known) __________ FEV/FVC (if known)___________
Inhaled therapy assessed?
Changes required? Y / N (details below)
Inhaler technique adequate?
Y / N (if no detail below)
Compliance assessed?: Good / Poor Reasons for poor compliance addressed? Y / N (details below)
Self management plan reviewed/ given
written / verbal (detail below)
Smoking cessation advice given
Referred smoking cessation Y / N / N/A
Annual flu vaccine received
Y / N Pneumococcal vaccine received Y / N
Referred pulmonary rehabilitation Y / N (details below
O2 saturations on discharge
COPD alert card issued
Y / N / N/A
PFTs arranged Y / N / N/A
Follow-up
Home visit respiratory nurse
Respiratory Consultant clinic
Signature
. ABG on air required Y / N (details below)
GP follow up
respiratory nurse clinic
Date
Counsel Patient on the following points:
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Prompt treatment of infection – recognition of an exacerbation
Annual influenza vaccination
One – off pneumococcal vaccination if not given previously.
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Follow Up: By most appropriate person-in either Primary or Secondary
Care
4 weeks post discharge:
• Evaluate symptoms and physical examination (as appropriate)
• Assess need for O2 (carried out by Respiratory Nurse)
• Measure SaO2 – ABG if SaO2 < 92% (carried out by Respiratory Nurse)
• Re-assess inhaler technique
• Measure FEV1
• Consider reversibility studies
• Ensure patient has Self Management Plan if appropriate
• Assess understanding of therapy and readjust as necessary
• Assess ability of patient to cope with their environment
• Check smoking status and offer advice if necessary
• Discuss flu vaccination and pneumococcal vaccination
• Discuss how to recognise the symptoms of an exacerbation and obtain prompt
treatment
• Discuss any social problems
Advance Care Planning
Palliative Care benefits patients through all stages of COPD because of their high
symptom burden that reduces physical, psychological and social functioning.
Advance Care Planning (ACP) is important in COPD because of the complex, often
unpredictable course of the disease and its multiple co-morbidities.
Timing of ACP discussions remains a challenge but discussions regarding this should be
commenced if:It would not be a surprise if the patient died in the next 6-12 months and/or the patient
has 2 or more of the following:a) Severe airways obstruction (FEV1 <30%) or restrictive deficit (FVC <60%,
Transfer factor <40%).
b) Meets criteria for LTOT (PAO2 <7.3 kpa).
c) Breathless at rest or on minimal exertion between exacerbations.
d) Persistent severe symptoms despite optimal tolerated therapy.
e) Symptomatic right heart failure.
f) Low body mass index (<21).
g) More emergency admission (>3) for infective exacerbations or respiratory
failure in the last year.
h) Has required intubation and ventilation or BiPap.
If the above criteria are met the following should be implemented:1)
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Assess patient and family for supportive and palliative care needs.
Review treatment/medication.
Plan care.
Consider GP putting on palliative care register.
Begin discussions regarding:
(a) Ceiling of treatment.
(b) DNA-CPR.
(c) Place of death.
The advance care plan should be shared with other services.
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