ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Recognition

Definition

• “Chronic Obstructive Pulmonary Disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible.” (WHO).
• It is also defined as having a post bronchodilator forced expiratory volume in one second divided by the forced vital capacity of the lungs (FEV1/FVC) < 0.70 predicted. (Gold spirometry 2010).

History

If possible, ascertain if patient has:

• Previous admissions with exacerbation of COPD
• Any admissions to Intensive Care Unit (ITU)
• Any allergies
• Home oxygen
• Home nebulisers

General symptoms

• Increasing cough and sputum
• Reduced exercise tolerance
• Clammy
• Sweaty
• Fever
• Changes in mental status

General Signs

• Tachypnoea
• Low oxygen saturations
• Use of accessory muscles
• Cyanosis
• Wheeze
• Pale
• Tachycardia
• Hypotensive

In-hospitality mortality score

• DECAF Score

Extended MRC Dyspnoea Scale - on a good day, within the last 3 months	Not too dyspnoeic to leave the house      0 Too dyspnoeic to leave the house but independent of washing and dressing     1 Too dyspnoeic to leave the house and to wash or dress     2
Eosinopenia	Yes         1	No          0
Consolidation on chest x-ray	Yes         1	No          0
Acideamia- pH <7.3	Yes         1	No          0
Atrial Fibrillation	Yes         1	No          0

• Increasing DECAF Score correlates with increased risk of in-hospital mortality

Initial Assessment and Investigations

• ABCDE assessment
• Sit patient up if able to tolerate
• Assess patient’s airway
• Monitor oxygen saturations and respiratory rate
  • If patient is hypoxic give Oxygen (O₂) to achieve target saturations. Initially give 15 L/min via a reservoir mask if the patient is acutely unwell
• Target saturations:
  • 94 - 98% for patients not at risk of hypercapnic respiratory failure
  • 88 - 92% for patients at risk of hypercapnic respiratory failure due to conditions such as Chronic Obstructive Pulmonary Disease (COPD)
• Examine patient’s chest
  • Listening for:
    • Decreased breath sounds
    • Expiratory wheeze
    • Coarse crackles
    • Hyper resonant (secondary pneumothorax)
• Arterial blood gas (ABG)
  • For information on Type 1 and Type 2 Respiratory Failure see “Common Causes of Respiratory Failure” Section in “Breathing” Chapter
• Chest X-ray should be requested. If the patient is unwell request a portable X-ray
  • Look for:
    • Hyperinflation
    • Consolidation
    • Pneumothorax
• Call for senior help
• Obtain intravenous access by placing 2 large bore cannulae in the antecubital fossa. Take blood to check Full Blood Count (FBC), Urea and Electrolytes (U&Es), Calcium, C-Reactive Protein (CRP)
• Consider blood and sputum cultures if sepsis is suspected
• Check Capillary Refill Time (CRT) - hold for five seconds and refilling should occur in 3 seconds
• Assess pulse rate, rhythm and character
• Monitor heart rate and blood pressure
• Listen to patient’s heart sounds
• Check urine output and consider catheterisation
• Intravenous (IV) fluids as required by clinical picture and balanced with patients’ risk of fluid overload. See more details in the “Circulation” Chapter in the “Response” Section under “Fluid Challenge”
• Consider sepsis six if sepsis suspected. For further information see “Sepsis” Section in “Medical Emergencies” Chapter
• Electrocardiogram (ECG) as this may show evidence of cor pulmonale. Cor Pulmonale is the enlargement of the right side of the heart following high blood pressure in the lungs. This leads to right sided heart failure
• Call for help if not already done
• Check pupils are equal and reactive
• Assess Glasgow Coma Scale or ACVPU using the NEWS2 chart
• Check patient’s temperature and blood sugar
• Examine patient’s abdomen and legs
• Consider venous thromboembolism prophylaxis

Response

Management

Immediate management

• Bronchodilators
  • Salbutamol 5mg nebulised with ~6 – 7 L/min Oxygen
  • If patient requires supplemental oxygen give with nasal cannula
  • Repeat as required. May need to be back to back
  • Ipratropium Bromide 500 micrograms nebulised with oxygen as above. This can be given 4 - 6 hrly
• Corticosteroids
  • Hydrocortisone 100 mg intravenously (IV) or Prednisolone 30 mg orally (PO)
• Antibiotics
• If evidence of infection
• Follow local guidelines
• Oxygen Therapy
• Ensure oxygen titrated to target saturations.
• For further information see “Response” Section in “Breathing” Chapter

Referrals

• Discuss with senior member of the team
• Contact critical care outreach team
• Referral to the respiratory team
• Referral to physiotherapy team
• Consider referral to Intensive Care Unit (ICU) if:
  • Failure to respond to medical management
  • Patient requires ventilatory support to encompass both NIV and invasive ventilation
  • Patient requires blood pressure support
  • Deterioration of blood gas following medical management
  • Changes in mental status

Future management

• Stop smoking advice
• Respiratory rehabilitation