COPD exacerbations: assessment and management Pat Fairclough, Dave Burns. Practice Nurse. Sutton: Feb 13, 2009.

Vol. 37, Iss. 3; pg. 21, 4 pgs

Abstract (Summary)
Airflow in a patient with COPD is already limited by the nature of the disease, and exacerbations will worsen this problem. Pulse oximetry (sometimes referred to as the 'fifth vital sign') is a convenient method of assessing the oxygen content of arterial blood. For patients with COPD, oxygen saturations below 92% are an indicator that the patient should be admitted to hospital for assessment of blood gases.

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(2706 words) Copyright Reed Business Information UK Feb 13, 2009 [Headnote] This article will consider the epidemiology, aetiology and pathophysiology of acute exacerbations of COPD, assessment of the patient who may be experiencing an exacerbation, and the management options COPD exacerbations are a significant cause of morbidity, have a substantial impact on healthcare budgets, and are associated with a more rapid decline in the patient's general health. EPIDEMIOLOGY, CAUSES AND PATHOPHYSIOLOGY COPD is common in the UK and worldwide. About 900,000 individuals have been diagnosed with COPD in the UK,1 and it is estimated that a further 3.7 million remain undiagnosed.2 The disease is usually classified according to the degree of lung function lost, although some people have low lung function and good performance status, while others have good lung function but poor performance status; that is, factors determining disease severity include breathlessness (assessed using the MRC dyspnoea scale), health status, exercise capacity, presence of cor pulmonale (lung disease complicated by right ventricular failure, fluid retention and chronic hypoxia) and frequency of exacerbations.1 Whatever the classification, at some point patients will probably face an acute exacerbation of COPD, which has been described as 'a worsening of the patient's condition, from the stable state and beyond normal day-to-day variation, that is acute in onset and necessitates a change in regular medication.'3 Patients with COPD have reduced airway calibre because of chronic inflammation and airway remodelling, and in an acute exacerbation, mucus hypersecretion and further airway wall oedema compound the problem. Increased effort is needed to 'shift' air in and out of the lungs, which can

prove extremely tiring. In addition, the difficulty of completely exhaling leads to air trapping and as a consequence, hyperinflation, which further compromises inspiratory effort and contributes to increasing hypoxia and hypercapnia (high levels of carbon dioxide). Unsurprisingly, the worse the patient's health and the more severe their COPD, the more likely they are to suffer an exacerbation. There is evidence that some patients prone to exacerbations because of their poor health status may enter a vicious circle, in that they may take as long as 3 months to recover to their 'baseline status', during which time they may develop another exacerbation. This pattern of ongoing exacerbations linked to an ever-decreasing health status makes for a cycle of decreasing lung function, health status and increasing exacerbation frequency. A variety of other factors, in addition to health status, have been implicated in the development of exacerbations. These include bacterial infection, viral infection, and atmospheric pollution in the form of, for example, sulphur dioxide, nitrogen dioxide and ozone, which may contribute to acute inflammation of the lungs. However, in one-third of acute exacerbations no obvious precipitating factor can be identified.4 DEFINING AN EXACERBATION Conventionally, it has been difficult to define an exacerbation of COPD. There are few studies of the disease process, and usual definitions describe symptoms (particularly dyspnoea) and alterations in sputum in terms of amount, colour and consistency. Other factors include reduced exercise tolerance, fatigue, cough, fluid retention and acute confusion.1 The severity of exacerbations can vary from mild (causing few problems) to severe (associated with respiratory failure and hospital admission). ASSESSING THE PATIENT There are several important criteria that can be used to confirm a suspected exacerbation of COPD. Vital signs Increased breathlessness is a key sign of an acute exacerbation of COPD. Infective exacerbations will induce pyrexia; this, along with possible hypoxaemia, will produce a tachycardia; the patient's respiratory rate will increase in an attempt to correct the hypoxaemia and perhaps to try to eliminate excess carbon dioxide. This may manifest in the use of accessory muscles and shallow breathing. The nature of the pulse may reveal other potential problems in addition to poor oxygenation, such as developing respiratory failure leading to carbon dioxide retention. Here the patient has warm peripheries, but may exhibit signs of confusion or drowsiness - the pulse may be slower than expected and will be 'bounding', in that it has a large volume. Pulse oximetry

Airflow in a patient with COPD is already limited by the nature of the disease, and exacerbations will worsen this problem. Pulse oximetry (sometimes referred to as the 'fifth vital sign') is a convenient method of assessing the oxygen content of arterial blood. For patients with COPD, oxygen saturations below 92% are an indicator that the patient should be admitted to hospital for assessment of blood gases. Note that pulse oximetry does not measure carbon dioxide levels, which are often elevated in those having an acute exacerbation of COPD who develop respiratory failure. Mental state Confusion or stupor can be signs that the patient is developing respiratory failure. If the patient is not well known to the clinician, getting more information on their usual mental state from a relative or carer may be helpful. In patients with severe COPD, mental deterioration during a severe exacerbation is an indicator that hospital admission is required.4 General physical appearance Is the patient cyanosed? Peripheral cyanosis may be usual for them but central cyanosis is a worrying sign. Is there evidence of dehydration? (This can be difficult to ascertain clinically in someone with a tachycardia or a dry mouth as a result of using oxygen therapy.) Are there signs of right-sided heart failure, such as ankle oedema (an important clinical sign) or elevated jugular venous pressure? The main issue is whether the patient can be managed at home, or needs hospital admission or care from a hospital at home scheme (if available). This will depend on factors such as the severity of their COPD, whether they are already on long-term oxygen therapy, and who is at home to care for them. Several other factors that might influence hospital admission are listed in Box I.4 MANAGEMENT Most acute exacerbations of COPD are managed in primary care, and many patients will selfmanage without assistance from healthcare professionals.5 There is also potential for some patients who would normally require hospital admission to be managed at home with input from specially trained nursing staff. This reduces the risk to the patient of nosocomial infections, enables them to stay in a familiar environment, and may provide economic benefits to the NHS.6 Four aims of management in an acute exacerbation of COPD are to relieve airflow obstruction, correct hypoxaemia, address comorbid disorders that may be contributing to the deterioration, and treat any precipitating factors such as infection.7 There are several treatment options to consider: * bronchodilators * steroids

* antibiotics * oxygen. Bronchodilators Bronchodilators, as described in the first part of this article ('Prescribing in stable COPD', Practice Nurse, 10 October 2008), relax airway smooth muscle, so opening up the lumen of the airway and facilitating airflow. This enables delivery of oxygen to the alveolar spaces and efficient removal of carbon dioxide. Patients will be using bronchodilators as part of their routine management, but the dose frequency will be increased in an acute exacerbation and the route of administration must be effective, so the use of a spacer or nebuliser should be considered. Salbutamol or ipratropium may be used (although recent GOLD guidelines state that a beta2-agonist is preferable), with the option of using the two in combination where response to an individual agent is poor.4 Steroids Patients with an FEV1 of less than 50% predicted, and/or experiencing two or more exacerbations per year will benefit from high-dose inhaled corticosteroids (ICS). However, in exacerbations, oral steroids have been shown to be beneficial. Oral corticosteroids can be given as short courses (30-40mg per day for 7 to 14 days), with no need to prescribe tapering doses where the patient is not taking oral steroids regularly. If the patient is on a regular oral corticosteroid, the increased dose given during an acute exacerbation will need to be reduced gradually until they are back on their regular dose. Advice about tapering is available in the British National Formulary. Antibiotics The use of antibiotics in an acute exacerbation of COPD is controversial.8 Common causative bacteria include Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis.4,9 However, numerous studies have failed to demonstrate any conclusive benefit to patients from the routine administration of antibiotics. Many guidelines and clinicians follow guidance10 that recommends antibiotic use where two of the following three criteria are present: * increased mucus expectoration * change in mucus colour * change in consistency of mucus. Generally, broad-spectrum agents are adequate, but the choice may be influenced by local microbiologist guidance as there may be particular issues with specific micro-organisms. Oxygen

Oxygen is given to reduce hypoxaemia, and is the cornerstone of management of COPD exacerbations.4 However, a well recognised problem in COPD patients is their reliance on a hypoxic drive as they become blunted to the usual hypercapnic drive. As a result, administration of oxygen can induce respiratory failure in some patients, so beginning or increasing oxygen in an exacerbation usually necessitates a hospital admission to allow close monitoring of arterial blood gases. Pulse oximetry can help guide the administration of oxygen, with guidelines stating that patients should have their oxygen saturations maintained at above 92%, or at least at their own personal best. For the reasons stated above, oxygen administration to patients with COPD who are experiencing an exacerbation should be carefully controlled, with the concentration being no higher than 28%, delivered through a Venturi mask. This level of administration should not be increased until blood gas analysis is available. REVIEW AND PREVENTION Once the patient is over the acute phase, appropriate review is essential, to carry out some fundamental tasks to ensure best stable management. These include: * checking of inhaler technique, which is well-known to be sub-optimal in many patients * going though how the exacerbation developed, with some emphasis on the early warning signs, may be helpful for the future * reminding patients of the importance of appropriate vaccinations * reminding patients who smoke of the benefits of stopping; after a frightening COPD exacerbation they may be receptive to cessation advice * offering general health advice about a balanced diet and exercise. Attending a pulmonary rehabilitation programme may reduce the impact of exacerbations, and regular physical activity has been shown to result in a lower risk of COPD-related hospital admission and death.11 There is evidence that certain pharmacological interventions can reduce the frequency of acute exacerbations of COPD. These include long-acting bronchodilators (anticholinergics and beta2agonists) and, as mentioned previously, inhaled corticosteroids. Use of these therapies is advocated by NICE1 and GOLD,4 as is influenza and pneumococcal vaccination. In addition there is growing recognition of the need to develop or investigate the use of action plans for acute exacerbations of COPD, in much the same way as in asthma management. Early recognition and treatment of an acute exacerbation of COPD has been shown to be associated with improved recovery, a reduced rate of hospitalisation, and better quality of life.12 It has also been shown that patients involved in a COPD selfmanagement programme had fewer

admissions for acute exacerbation, and fewer emergency attendances for, and fewer unscheduled visits to their GP, reducing the costs associated with COPD management.13 The British Lung Foundation has devised a self-management plan for patients with COPD that includes advice on recognising and treating exacerbations, which may be helpful for selected patients. CONCLUSION Acute exacerbations may cause significant problems for patients with COPD, and studies have shown that these episodes are what they fear most. Patient education may help to initiate early recognition and prompt treatment, although it has been found that almost two-thirds of COPD patients are able to identify the onset of an exacerbation.14 Thorough assessment of the patient is vital, with clinicians being aware that where the exacerbation is severe, and/or there is concern about the development of respiratory failure, hospital admission may be necessary. [Sidebar] Prescribing Nurse is for all of you, but especially for prescribers. This section of the journal keeps you up to date with everything you need to know about administering and prescribing medicines. [Sidebar] Fairdough P. Bums D. ~PD exacerbations: assessment and management. Practice Nurse 2009; 37(3): 21-26 Date received: 25 November 2008 Date accepted for publication: 17 December 2008 [Sidebar] BOX 1. INDICATIONS FOR HOSPITAL ASSESSMENT OR ADMISSION IN PATIENTS WITH AN EXACERBATION OF COPD4 * Marked increase in intensity of symptoms, such as sudden development of resting dyspnoea * Severe underlying COPD * Onset of new features (eg cyanosis, peripheral oedema) * Failure of exacerbation to respond to initial treatment * Significant comorbidities * Frequent exacerbations * Newly occurring arrhythmias * Diagnostic uncertainty * Older age * Insufficient home support Airflow in a patient with COPD is already limited by the nature of the disease, and exacerbations will worsen this problem [Sidebar] Oxygen is given to reduce hypoxaemia, and is the cornerstone of management of COPD exacerbations

[Sidebar] COPD EXACERBATIONS: PRACTICE POINTS *A patient with COPD who develops tachycardia may have been increasingly or excessively using beta2-agonists, perhaps through a nebuliser. In these circumstances, some of the rise in heart rate may be a side-effect of the use of beta2-agonists *Oxygen saturation in patients with COPD should be recorded between exacerbations to enable realistic assessment *Patients with COPD often have comorbidities, so be alert to the possibility that another problem may be developing alongside the exacerbation, such as pneumonia, left heart failure or lung cancer *Co-existing problems such as diabetes or heart failure can be affected by or contribute to an exacerbation. There must be consideration of the patient's entire treatment as adjustments may be required. These more complex situations may well contribute to the decision to admit the patient to hospital *Not everyone with COPD is able to self-manage an exacerbation. Therefore patients must be carefully selected and monitored. Some will benefit from a full self-management programme, while others just need to know what to look out for and when and how to contact their healthcare provider. Patients should contact their healthcare provider as soon as possible after starting selfmedication in the event of an exacerbation [Sidebar] RESOURCES * NICE Clinical Guideline Chronic obstructive pulmonary disease. NICE, 2004 www.nice.org.uk/CG12 * Global Strategy for the Diagnos Management, and Prevention of COPD GOLD, 2008 www.goldcopd.org * British Lung Foundation www.lunguk.org * Emergency Oxygen Use in Adult Patients British Thoracic Society, 2008 www.brit-thoracic.org.uk [Reference] REFERENCES 1. NICE. Clinical Guideline. Chronic obstructive pulmonary disease. London: NICE, 2004. www.nice.org.uk/CG12 2. Shahab L, Jarvis MJ, Britton J, West R. Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax 2006; 61:1043-47. 3. Rodiguez-Roisin R. Toward a consensus definition for COPD exacerbation. Chest 2000; 117(5, suppl): 398-401. 4. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD. GOLD, 2008. www.goldcopd.org 5. Seemungal TAR, Donaldson CG et al. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 157, 1418-22. 6. Ram F, Wedzicha JA, Wright J, Greenstone M. Hospital at home for patients with acute exacerbations of COPD: systematic review of evidence. Br Med J 2004; 329, 315-9.

7. McNee W. Acute exacerbations of COPD. Swiss Med Weekly 2003; 133, 247-57. 8. Miravitlles M, Torres A. Antibiotics in exacerbations of COPD: lessons form the past. Eur Respir J 2004; 24: 896-7. 9. Tsoumakidou M, Siafakas N. Novel insights into the aetiology and pathophysiology of increased airway inflammation during COPD exacerbations. Respir Res 2006; 7(1): 80. 10. Anthonisen NR, Manfreda J et al. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 1987; 106: 196-204. 11. Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Anto JM. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax 2006; 61: 772-8. 12. Wilkinson T, Donaldson G, Hurst J, Seemungal T, Wedzica J. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2004; 169: 1298-30. 13. Bourbeau J, Julien M et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a diseasespecific self-management intervention. Arch Intern Med 2003; 163; 585-91. 14. Kessler R, Sthl E et al. Patient understanding, detection, and experience of COPD exacerbations. Chest 2006; 130: 133-42. [Author Affiliation] Pat Fairclough, MSc, RON, respiratory nurse, Southport and Ormskirk Hospitals, associate lecturer, Respiratory Education UK; Dave Burns, RON, MSc, RNT national training manager, Respiratory Education UK
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Subjects: Classification Codes Locations: Author(s): Author Affiliation: Document types: Document features: Section: Chronic obstructive pulmonary disease, Medical treatment, Medical diagnosis, Guidelines 9175 Western Europe, 8320 Health care industry, 9150 Guidelines United Kingdom--UK Pat Fairclough, Dave Burns Pat Fairclough, MSc, RON, respiratory nurse, Southport and Ormskirk Hospitals, associate lecturer, Respiratory Education UK; Dave Burns, RON, MSc, RNT national training manager, Respiratory Education UK Feature Photographs, References prescribing nurse

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Practice Nurse. Sutton: Feb 13, 2009. Vol. 37, Iss. 3; pg. 21, 4 pgs Periodical 09536612 1656071361 2706

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