Acute Exacerbation Of COPD

A sudden worsening of symptoms that cannot be controlled with normal medication regime and is beyond day-to-day variations. Exacerbations are most commonly caused by infections.
They can be classified into varying degrees of severity:

  • Mild- treated with short acting bronchodilators only, SABDs
  • Moderate- treated with SABDs plus antibiotics and/or oral corticosteroids
  • Severe- requires hospitalisation and may be associated with acute respiratory failure.

Presentation

Acute worsening of breathlessness
Cough- increase in sputum production, or change in colour/appearance of sputum

Examination

Oxygen Saturations
Blood pressure
Temperature
Respiratory Rate
Signs of hypoxia
Signs of consolidation- coarse crepitations, dull percussion, increased vocal resonance
Wheeze

No respiratory failure: Respiratory rate: 20-30 breaths per minute; no use of accessory respiratory muscles; no changes in mental status; hypoxemia improved with supplemental oxygen given via Venturi mask 28-35% inspired oxygen (FiO2); no increase in PaCO2.

Acute respiratory failure —non-life-threatening:Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; no change in mental status; hypoxemia improved with supplemental oxygen via Venturi mask 25-30% FiO2; hypercarbia i.e., PaCO2 increased compared with baseline or elevated 50-60 mmHg.

Acute respiratory failure —life-threatening:
Respiratory ra
te: > 30 breaths per minute; using
accessory respiratory muscles; acute changes in mental status; hypoxemia not improved with
supplemental oxygen via Venturi mask or requiring FiO
2

40%; hypercarbia i.e., PaCO

2
increased
compared with baseline or elevated

60 mmHg or the presence of acidosis (pH

<
7.25).

Investigations and Diagnosis

If a patient is referred to hospital then investigations carried out should include:

  • chest radiograph
  • ABG
  • ECG- to exclude comorbidities
  • FBC & U+E's
  • a theophylline level should be measured in patients on theophylline therapy at admission
  • sputum culture- if purulent
  • blood cultures- if febrile

Diagnosis is a clinical judgement not dependent on results of specific investigations

Management

Inhaled therapy

http://bestpractice.bmj.com/best-practice/monograph/8/treatment/details.html

Systemic corticosteroids
Given to all patients if no significant contraindications
Typically Oral Prednisolone 30mg 5-7 days- consult local guidelines
It is recommended to keep courses below 14 days
Consider osteoporosis prophylaxis for patients on long term treatment or requiring frequent steroid courses

Antibiotics
If presenting with purulent sputum or signs of consolidation on chest radiograph or signs of pneumonia
Initial empirical treatment should be an aminopenicillin, a macrolide, or a tetracycline- consult local microbiological guidelines

Theophylline
Should only be used as an adjunct if there is an inadequate response to bronchodilators
IV administration
Monitor levels within 24 hours of starting treatment

Oxygen Therapy

https://www.nice.org.uk/guidance/cg101/chapter/1-Guidance#management-of-exacerbations-of-copd

Prevention

Smoking cessation
Regular vaccinations- HiB (yearly), pneumoccocal vaccine (every 5 years)
Compliance and correct technique when taking medications
Good diet and fluid intake
Exercise

Prior to discharge

Spirometry should be measured in all patients
Patients should be re-established on their optimal maintenance bronchodilator therapy before discharge
Satisfactory oximetry or arterial blood gas results
Assess normal therapeutic regime
Ensure patient and/or carers are fully informed and understand the correct use of medications and oxygen
Make arrangements for follow-up and home care (such as visiting nurse, oxygen delivery, referral for other support)
Be sure the patient is going to be able to manage successfully at home

Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-ShareAlike 3.0 License