Professional Documents
Culture Documents
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
Increased breathlessness
Increased wheeziness
Chest tightness
Increased cough
Increased sputum purulence
Uncommonly fever
3. Differential Diagnosis
Pneumonia
Pneumothorax
Left Ventricular Failure/Pulmonary Oedema
Pulmonary Embolisim
Lung Cancer
4. Severity Assessment
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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6. Investigations to consider
The diagnosis of an exacerbation is made clinically
Primary Care
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
patients 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
Corticosteroids oral
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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Chest Physiotherapy
Smoking Cessation
Diuretic
Oral furosemide if indicated
Nutrition
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+
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Systemic Corticosteroids
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 patients condition allows.
Check BM once daily in all patients and four times daily in diabetic patients
and maintain tight control of blood sugars.
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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Intravenous aminophylline
Chest Physiotherapy
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
Diuretic
Ace Inhibitors
Thromboprophylaxis
Nutrition
Fluids
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NIPPV
Respiratory Stimulants
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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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.
. Date (time)
.
(if no detail below)
.
Signature
GP follow up
Date
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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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