Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)
COPD is a chronic, usually progressive, disorder characterised by airflow obstruction with little reversibility and usually >20 pack years of smoking. An acute exacerbation may be described as a worsening of a stable situation.
Common features - increased:
- Sputum (volume or purulence)
Assessment / monitoring
- Arterial blood gases (document oxygen therapy)
- U&Es, LFTs, and CRP
- Theophylline level (if patient on theophylline)
The differential diagnosis includes:
- Pneumonia, pneumothorax, pulmonary embolus
- Left ventricular failure
- Lung cancer
- Oxygen 28% via venturi mask until gases checked - then titrate according to arterial blood gases.
- Aim for PaO2 >7.5kPa but <10kPa. If worsening respiratory acidosis or hypercapnia occurs, despite achieving target oxygen levels and adequate immediate therapy, ventilation may be indicated – see Non-invasive ventilation (NIV) protocol in COPD.
- Nebulised: Nebulisation should be with air. Supplementary oxygen (1-6L/minute to maintain oxygen saturation 88-92%) can be given by nasal cannula during nebulisation. If air driven nebuliser is not available, use up to 6L/minute of oxygen for a maximum of 10 minutes to drive nebuliser. Use a mouth-piece or close fitting mask to avoid risk of acute angle-closure glaucoma with ipratropium.
- Salbutamol 5mg nebules four times daily (but can be given up to 2 hourly as needed)
- Ipratropium 0.5mg nebules four times daily (add if poor response to salbutamol and if also on tiotropium, withold the tiotropium)
- IV bronchodilators: Aminophylline may be considered if there is no response to nebulised therapy.
- N.B. The evidence for aminophylline is not conclusive although individual patients may benefit. Discuss with senior doctors. Side effects include nausea, seizures and it can precipitate arrhythmias.
- Aminophylline infusion – dose administration and monitoring guidance see Appendices 2 and 3.
- Prednisolone oral 30mg-50mg each morning, for 7 days. Refer to local unit protocols for more detail or if patient is unable to take oral treatment give:
- Hydrocortisone IV 100mg immediately then review, and if there is a need to continue IV therapy, prescribe 50-100mg 6-8 hourly.
- Indicated in the presence of purulent sputum, raised inflammatory markers or focal radiological changes. They should be given orally unless there is a clinical reason for giving IV antibiotics. Send sputum for microscopy and culture. For antibiotic choice and course duration see lower respiratory tract infections treatment guideline
- Note: Serious drug interactions with clarithromycin (see BNF Appendix 1) and QTc prolongation.
- DVT Prophylaxis:
- Enoxaparin SC 40mg once daily (reduce to 20mg daily if eGFR <30ml/minute/1.73m2).
- but N.B. there is no data to support emergency call out.
- If persistent acidotic hypercapnic ventilatory failure despite optimal medical therapy consider discussion with ITU and/or non-invasive ventilation (NIV) protocol
- Mucolytic therapy may be of symptomatic benefit in patients where sputum clearance is troublesome:
- Carbocisteine oral 750mg three times daily then reduced to 1.5g daily in divided doses as condition improves.
- Nicotine replacement therapy if appropriate (see Appendix 1).
- Consider for referral to early supported discharge team (British Lung Foundation Nurses).
Prior to discharge
- Check inhaler technique and drug regimen: stop nebulised bronchodilator for 24 hours prior to discharge (if not used at home and not discharged under early supported discharge protocol). Home nebulisers should not be introduced as routine treatment immediately after acute exacerbation.
Prednisolone oral 30mg-50mg each morning for 7 days, without dose tapering, will be suitable for most patients.
N.B.There may be circumstances however where a tapering dose is necessary, e.g. in patients who are oral steroid dependent. In such circumstances reduce the dose to the normal maintenance dose or 10mg daily (whichever is the greater) with a plan for early outpatient review or refer to local unit protocol.
Clinical improvement with oral steroids in acute COPD does not indicate need for long-term inhaled steroid.
- Physiotherapy advice regarding pulmonary rehabilitation.
- Smoking cessation advice and referral if appropriate (see Appendix 1).
- Home oxygen is usually assessed as an outpatient when patients are stable for at least 6 weeks post exacerbation and an ex-smoker or non-smoker.
- Ensure optimal inhaled medication prior to discharge (see Management of COPD guideline).