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Acute Exacerbation of COPD

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Goal of treatment in acute exacerbation of COPD with Type 2 failure is to achieve a PaO₂ (> 7.0 kPa (52 mmHg)) without increasing PaCO₂ and acidosis, while identifying and treating the precipitating condition.

Acute Exacerbation of COPD Initial care: Get help if not responding
Give 24-28% O₂ or room air for sats of 88-92%. Use venturi mask and if not tolerated nasal oxygen may be tried Check initial ABG and continue therapies often started in ED Salbutamol [Albuterol] 5 mg + Ipratropium Bromide 500 mcg with 24-28% O₂ Prednisolone 30 mg stat PO and/or Hydrocortisone 200 mg IV Portable CXR if unstable. Department CXR if stable Keep accompanied ABG after 1 hour. NIV if pH < 7.35 or CO₂ rise. For those who cannot tolerate/have NIV consider Doxapram Anaesthetic review for Intubation if worsening respiratory failure Mechanical ventilation if pH <7.26 and PaCO₂ is rising despite NIV Consider IV antibiotics if bacterial infection likely Some may consider IV Aminophylline Determine ceiling of care and resuscitation and ventilation status

Acute Exacerbation of COPD Initial care: Get help if not responding

Give 24-28% O₂ or room air for sats of 88-92%.
Use venturi mask and if not tolerated nasal oxygen may be tried
Check initial ABG and continue therapies often started in ED
Salbutamol [Albuterol] 5 mg + Ipratropium Bromide 500 mcg with 24-28% O₂
Prednisolone 30 mg stat PO and/or Hydrocortisone 200 mg IV
Portable CXR if unstable. Department CXR if stable Keep accompanied
ABG after 1 hour. NIV if pH < 7.35 or CO₂ rise.
For those who cannot tolerate/have NIV consider Doxapram
Anaesthetic review for Intubation if worsening respiratory failure
Mechanical ventilation if pH <7.26 and PaCO₂ is rising despite NIV
Consider IV antibiotics if bacterial infection likely
Some may consider IV Aminophylline
Determine ceiling of care and resuscitation and ventilation status

Note: The fixed combination of an inhaled glucocorticoid and a LABA improves lung function, reduces the frequency and severity of exacerbations, and enhances the quality of life in COPD patients.

Background

Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable, and treatable disease.
Characterized by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities.

Causes

Significant exposure to noxious particles or gases.
Smoking is the most important risk factor.
Environmental exposures, such as biomass fuel exposure and air pollution, may contribute.
Severe hereditary deficiency of alpha-1 antitrypsin.
Higher prevalence in females and lower socioeconomic status.

Chronic Symptoms

Chronic progressive dyspnoea, cough, and/or sputum production.
Periods of acute worsening of respiratory symptoms, known as exacerbations.
Significant comorbidities increase morbidity and mortality.

Common Comorbidities

Cardiovascular disease, skeletal muscle dysfunction.
Metabolic syndrome, osteoporosis, depression, anxiety, lung cancer.

Investigations

Spirometry: Required to make the diagnosis; a post-bronchodilator FEV1/FVC ratio <0.70 confirms the presence of persistent airflow limitation.
Chest X-Ray (CXR): Shows changes in advanced disease, such as hyperinflation and flattened diaphragms.

Exacerbation: Patient Assessment

Symptoms: Increased breathlessness, wheezing, sputum production, fatigue.
Physical signs: Use of accessory muscles, pursed-lip breathing, cyanosis, tripod position.
End-stage COPD patients may be cachectic and frail.
If the patient is in extremis or hypoventilating, seek urgent anaesthetic support and critical care.
Review previous admissions and the need for ICU or NIV (Non-Invasive Ventilation).

Initial Investigations

Blood Tests: FBC, U&E, LFT, CRP. Elevated WCC and CRP may suggest infection.
CXR: Look for consolidation, pneumothorax, and signs of emphysema.
ECG: Check for sinus tachycardia, RVH, P pulmonale, and RBBB.

Management in the First Hour

Obtain ABG to assess severity and establish IV access. Check for respiratory failure and elevated pCO₂.
Administer 24-28% oxygen therapy; aim for pO₂ > 8 Kpa with a minimal increase in CO₂.
Nebulisers: Salbutamol 5 mg 4-hourly and Ipratropium Bromide 0.5 mg 4-hourly.
Start IV fluids; consider potassium replacement if needed due to hypokalaemia from beta-agonists.
Steroids: Prednisolone 30 mg orally for 7 days and/or IV Hydrocortisone 100 mg 8-hourly.
Antibiotics: Indicated if bacterial infection is suspected. Options include Amoxicillin, Doxycycline, or Clarithromycin.
Review any advanced care plans that specify a ceiling of care.

Management in 1-2 Hours

Check ABG and assess for NIV if pH < 7.35 and pCO₂ > 6 Kpa (45 mmHg).
Consider intubation if pH < 7.26 and pCO₂ > 6 Kpa (45 mmHg) and discuss with intensivists or respiratory specialists.
Review and re-establish the ceiling of care; consider DNACPR decisions.
For patients who are dying, focus on providing compassionate palliation.

Non-Invasive Ventilation (NIV) Settings

Criteria: Awake, cooperative patient who can tolerate the mask and protect their airway.
Initial Settings: IPAP 10 cmH₂O and EPAP 4 cmH₂O.
Adjustments: Increase IPAP to 20 cmH₂O as needed, monitor for leaks and adjust settings accordingly.
Monitoring: Check ABG after 1 hour and with every parameter change. Be prepared to escalate to intubation if necessary.

Discharge Planning

Follow-up with respiratory nurse for education, advice, and rehabilitation.
Emphasize smoking cessation with pharmacotherapy and nicotine replacement.
Prescribe LABA, LAMA, and inhaled corticosteroids as indicated.
Ensure patients receive influenza and pneumococcal vaccinations.
Discuss advanced care planning for patients with severe disease.

Criteria for Home Oxygen Therapy

Long-term oxygen therapy improves survival in patients with severe resting hypoxemia.
Eligibility: PaO₂ ≤ 7.3 kPa (55 mmHg) or SaO₂ ≤ 88%, confirmed twice over 3 weeks.
PaO₂ between 7.3-8.0 kPa (55-60 mmHg) if evidence of pulmonary hypertension or other conditions.

References

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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