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Home | Articles | Respiratory | Exacerbation of COPD

Exacerbation of COPD

Last updated 23rd January 2024

Referral to Respiratory Nurse Specialist

  1. All patients with exacerbation COPD should be referred to a respiratory nurse specialist for consideration of early supported discharge. 
  2. Contact details for the Respiratory Nurse Specialists are: – Yvonne Scott 32007, Susan McGill 31576, John Duncan 33924
  3. Click here for link to the Early Supported Discharge (ESD) Form which you should send to [email protected].  This form can be used out of hours or on Mon-Frid 9-5 when the respiratory team are unable to attend AMU/ED due to other commitments.

Definition

  1. Sustained worsening, acute in onset, of patient’s symptoms beyond normal day to day variations in state
  2. Commonly associated with increase in SOB, cough, sputum and/or wheeze
  3. Remember that respiratory reserve is significantly reduced in more advanced COPD and that many acute illnesses can drive worsening SOB

Causes

  1. Not all are bacterial. Viruses and non infectious agents may also be responsible.

Co-morbidities     

  1. Many patients with COPD have other life changing diagnoses such as ischaemic heart disease and heart failure. These will also impact on presentation and prognosis and appropriate priorities of care.

Co-presentation

  1. Patients with background of COPD also develop other problems during exacerbations, sometimes new at presentation to hospital. These can include
    • Pneumonia
    • Worsening CO2 retention
    • Pneumothorax
    • Heart failure
    • PE
    • Lung cancer

Key Questions

  1. Previous COPD related admission history
  2. Appropriate goals of therapy and anticipation planning – may need discussion with senior
  3. Current level of breathlessness, graded using MRC dyspnoea scale
  4. Usual level of breathlessness
  5. Any change in sputum colour or volume
  6. Smoking history, cannabis use, vaping history
  7. Maintenance (or previous use of) oral steroid
  8. Nebuliser at home?
  9. Domiciliary oxygen? Long term use or ambulatory

Shifts in Concepts of Care

  1. Many exacerbating COPD patients, particularly if only moderately exacerbating, when sufficiently medically stabilised can be effectively managed at home via early supported discharge pathways and admission avoidance pathways
  2. Keeping vulnerable chests away from further infections can improve well-being
  3. Good COPD care is in partnership with the patient and self-management plans ± COPD app ± rescue packs can provide a corner-stone to effective care

Investigations

  1. Bloods including FBC, U&E and CRP
  2. SpO2 on air and on oxygen
  3. ABG  – if acute ventilatory failure see Bi-level NIV S/T Guidelines for CCU and Bi-level NIV S/T Guidelines for ED
  4. CXR
  5. ECG
  6. Microbiology – especially sputum culture
  7. Theophylline level if on theophylline

Initial Management

  1. Controlled oxygen therapy – with appropriate oxygen target documented and prescribed
  2. Nebulised bronchodilators
  3. Oral steroid
  4. Physiotherapy
  5. Antibiotic if fever, raised CRP, changes in sputum or radiological evidence of infection

Controlled Oxygen Therapy

  1. The challenge in COPD is to correct hypoxaemia without switching off hypoxic drive to respiration and without provoking or worsening hypercapnia or acidosis
  2. All patients with moderate or severe COPD especially those with previous respiratory failure or on long term oxygen, are at risk of hypercapnic respiratory failure
  3. Clues to severity come from FEV1, the need for combined LAMA plus LABA plus ICS to control symptoms, poor baseline exercise tolerance (inability to climb flight of stairs is a useful marker) and previous documentation of CO2 retention and/or previous need for NIV
  4. If yes to above then target SpO2 88-92% start oxygen if needed at 2l/min by nasal prongs or 24% or 28% by venturi mask in order to achieve target sats and then check ABG on oxygen
  5. If target sats cannot be reached with any of these measures then seek senior input
  6. Recheck ABG after further 30-60 minutes – it takes this long for the CO2 to find a new steady state
  7. Note the ABG must be arterial and venous sampling is not sufficient to accurately interpret HCO3 and PCO2
  8. NB patient may carry an alert card with pre-specified SpO2 target range

Nebulised Bronchodilators

  1. Rx regular nebulised Salbutamol 5mg 4-6 times daily
  2. If the patient is still able to effectively take their usual LAMA then switch to nebulised with ipratropium 0.5mg 4-6 times daily may not offer additional benefit to adherence to usual LAMA or LAMA containing usual inhaled device
  3. If giving ipratropium nebs, always use a mouthpiece or close fitting mask to avoid risk of acute narrow angle glaucoma
  4. Withold any LAMA or LAMA containing combination inhaler if receiving ipratropium nebs
  5. If patient is hypercapnic or acidotic the nebuliser should be driven by compressed air and not oxygen – if oxygen is needed it should be given simultaneously by nasal cannulae.
  6. Convert to hand held inhaler device as soon as stable as nebulised therapy no more effective and hand held inhaled therapy may permit earlier discharge. Consider use of spacer device if using metered dose inhaler.
  7. Green inhaler prescribing information can be found at https://www.nhsdghandnhsdghandbook.co.uk/medical-handbook/greener-inhaler-prescribing/
  8. Do not start home nebulisers routinely after acute exacerbation

Oral Steroid

  1. Prednisolone 30mg orally should be given for 5-7 days to all patients with exacerbation COPD unless contraindicated
  2. Usually no advantage in treating for longer than 7 days
  3. Consider bone prophylaxis and gastroprotection if frequent courses oral steroid required
  4. Consider more gradual withdrawal of prednisolone if has:
    • already taken 40mg daily or more for more than one week
    • already received more than 3 weeks treatment
    • recently received repeat course of steroid
    • taken a short course within 1 year of stopping long term therapy
    • other causes of adrenal suppression
  5. See BNF for more advice on steroid withdrawal – Click to View the BNF Section on Glucocorticoid Therapy

Physiotherapy

  1. Chest physio, breathing control and general physio are all important factors of care to consider
  2. Pulmonary rehabilitation after discharge is often appropriate

Antibiotics

  1.  If antibiotics are indicated (see above) their choice should be guided by NHSD&G Antibiotic Guidelines Poster – Adults in Secondary Care. Usual duration of therapy for bacterial IECOPD is 5 days.

Theophyllines as per BTS/NICE guidelines

  1. Only use intravenous theophylline as an adjunct to exacerbation management if there is an inadequate response to nebulised bronchodilators
  2. Take care when using intravenous theophylline because of its interactions with other drugs and potential toxicity if the person has been taking oral theophylline
  3. Monitor theophylline levels within 24 hours of starting treatment , and as frequently as indicated by the clinical circumstances after this

Mucolytic Therapy

  1. May be of benefit if sputum thick and difficult to clear
  2. Once daily 600mg N acetylcysteine effervescent is effective and easy     
  3. Speak with physio re non-pharmacological devices and techniques to aid sputum clearance

Referral to Respiratory Nurse Specialist

  1. All patients with exacerbation COPD should be referred to a respiratory nurse specialist for early supported discharge. 
  2. This review will also include COPD discharge bundle. Yvonne Scott 32007, Susan McGill 31576, John Duncan 33924

Check List for Hospital Discharge

  1. Check referred to respiratory nurse specialist
  2. Consider early supported discharge – see link below.
  3. Stop nebulisers for 24 hours before discharge – unless used at home, or going home as early supported discharge
  4. Check inhaler technique
  5. Ensure optimal inhaled medication
  6. Clarify whether oral steroid to be stopped at 5 days (suitable for most patients) or tapered (for reasons given earlier)
  7. Smoking cessation advice and referral if appropriate

LTOT After Admission with COPD Exacerbation

  1. Any need for long term home oxygen is usually assessed in outpatient setting once stable for at least 4-8 weeks, though earlier review is indicated if there is also indication for NIV with LTOT
  2. The MRC dyspnoea scale :
    • Grade 1 – Not breathless except on strenuous exercise
    • Grade 2 – SOB when hurrying on level or walking up a slight incline
    • Grade 3 – Walks slower than most people, stops after a mile or so or stops after 15 minutes walking at own pace
    • Grade 4 – Stops for breath after 100 yards, or after a few minutes on level ground
    • Grade 5 – Too breathless to leave house as SOB while washing and dressing

Links

Content updated by Kate Boyle, Yvonne Scott & Stuart LIttle