Chronic Obstructive Pulmonary Disease (COPD)

 

The flowchart and information on this page is intended to assist in the appropriate assessment and management of patients presenting to the emergency department with acute exacerbations of COPD

 

COPD Flowchart

COPD flowchart-page-001-2

 
 

Notes on the guideline – Management of acute exacerbations of COPD

Definitions

COPD exacerbation – an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnoea, cough and/or sputum that is beyond normal day to day variations, is acute in onset, and may warrant a change in regular medications in a patient with underlying COPD.1

This guide aims to provide a framework to manage an infective or noninfective exacerbation of COPD, as well as prompt consideration of important comorbidities and differential diagnoses in this group of dyspnoeic patients.

Inclusion Criteria

  • Known COPD
  • Suspected first presentation COPD eg Long term smoker with SOB and wheeze

Exclusion Criteria

  • Acute presentation more consistent with alternative cause of dyspnoea eg pulmonary embolism, CCF or asthma

Red Flags

The following high-risk features should alert the physician to a severe exacerbation of COPD or potential for rapid deterioration.

  • Altered mental status – drowsy or agitated
  • History of ICU admission/intubation
  • On home oxygen
  • FEV1 < 40% predicted
  • Pleuritic chest pain (consider PE or pneumonia)
  • Ischaemic chest pain/ichaemic changes on ECG
  • New arrhythmia
  • Concurrent left or right sided heart failure

Assessment

Assessment is directed at establishing;

  • The diagnosis of a COPD exacerbation
  • The severity of exacerbation
    • A severe exacerbations is characterized by;2
      • Ill appearance, sweaty, agitated or drowsy
      • Severe dyspnoea not responsive to bronchodilation
      • Respiratory acidosis (pH < 7.3) or new/worsening CO2 retention (> 70 mmHg) on blood gas analysis
      • Worsening hypoxaemia
      • FEV1 < 40% predicted
    • The presence of
      • CCF
      • Cor pulmonale
      • Pneumonia
      • Bullae/PTX
    • The possibility of alternative life-threatening diagnosis
      • CCF
      • PE
      • ACS
      • Arrthymia
      • Pneumonia

History

  • Increased dyspnoea, cough or sputum production/purulence
  • Chest pain
  • Risk factors for PE
  • Leg swelling
  • Fever
  • Baseline functional capacity, change in functional capacity
  • Frequency of exacerbations
  • Home treatments (including home oxygen)

Examination

  • Work of breathing
  • Mental status
  • Wheeze or decreased breath sounds
  • Signs of right or left heart failure

Investigations

  • In all patients
    • ECG
    • Chest x ray
    • FBP and U E C
  • In most patients
    • Blood gas analysis – venous (majority) or arterial.3,4 Indicated in all patients unless mild exacerbation and no history of CO2 retention. Record Fi02 or oxygen rate and delivery at time of sampling. Compare to previous results. Serial blood gas measurement in all patients on BIPAP
  • In some patients
    • Spirometry : Useful in the undifferentiated dyspnoeic patient eg pulmonary oedema Vs COPD. May initial be too unwell to perform
    • Sputum MC&S – as requested by the inpatient team
    • Investigation of differential diagnosis if indicated – eg troponin

 

Management

Involves directed therapies aimed at relieving airflow limitation, hypoxia and hypercapnia as well as decreasing sputum production and airway inflammation.

  • Controlled oxygen therapy5,6
    • Via nasal prongs 0.5-2 L/minute or via a venturi mask at 24%-28%. Aim for saturations 88-92%. Saturations > 92% give no added benefit and may reduce hypoxic ventilatory drive.
  • Bronchodilators7,8
    • Salbutamol 5 mg via nebuliser or 10 puffs via MDI and spacer . Frequency is dependent on the severity of exacerbation and response to treatment – e.g. mild 1-6 hourly, severe initially 20 minutely or continuous.
    • Ipratropium 500mcg via nebuliser or 2-6 puffs via MDI and spacer. Initially up to 20 minutely x 3 doses in severe exacerbation, then 4-6 hourly.
    • Change to MDIs with a spacer as soon as tolerated.
  • Glucocorticoids9
    • Indicated in all patients
    • Prednisolone 30-50mg po od for 7-14 days – for mild-moderate exacerbations
    • Hydrocortisone 100mg QID IV – for severe exacerbations or if oral medications are not tolerated.
  • Antibiotics10
    • Indicated if
      • increased cough
      • increased volume or purulence of sputum
      • fever or leucocytosis
      • evidence of pneumonia on CXR.
    • Oral agents are used in the majority of cases
    • IV agents are reserved for severe infective exacerbations, intolerance of oral medications or lobar pneumonia on CXR
    • Typical oral agents are;
      • Amoxycillin 500mg QID po for 5 days
      • Doxyclycline 100mg bd po for 5 days
    • IV antibiotic therapy is based on the initial treatment of community-acquired pneumonia (see therapeutic guidelines), however consider any recent sputum culture results or known colonization with pseudomonas.
  • BIPAP11
    • Is highly effective in COPD with good supporting evidence and if indicated should be instituted early in the patient’s ED course
    • Indications
      • Severe SOB with poor response to bronchodilators
      • Confusion/lethargy
      • Worsening hypoxia despite treatment
      • Worsening (over baseline) or new hypercapnia
      • pH < 7.3
    • Exclusion criteria
      • Inadequate seal – eg facial abnormailites
      • Unable to protect airway
      • Vomiting
      • Inadequate/nil spontaneous breaths
      • Haemaodynamic instability – hypotension, uncontrolled arrhythmias
    • As a guide, start with IPAP 12 mmHg, EPAP 6 mmHg and Fi02 with target oxygen saturations 90-92%. Adjust pressures according to clinical response.
    • Once instituted patient requires serial blood gas analysis and frequent clinical review
  • Intubation and ventilation11
    • Is indicated if meets exclusion criteria for BIPAP, is in extremis or has arrested. Discuss with senior doctor
    • Consideration must be given to any patient’s prior directives regarding limitation to treatment and patient’s short-term prognosis before initiating intubation and ventilation.
    • Use ketamine as an induction agent
    • In order to reduce ventilator induced lung injury, employ a permissive hypercapnia ventilation strategy
    • Suggested initial ventilator settings;
      • Mode – assist control
      • RR 8-10 bpm
      • Tidal volume 6 ml/kg
      • PEEP 5 mmHg
      • FiO2 1.0
    • Requires serial ABGs (arterial line) and continuation of medical therapy

Disposition

  • Criteria for safe discharge from the emergency department2
    • Inhaled bronchodilators required less than four hourly
    • Oxygen saturations > 88%
    • If previously able, the patient is ambulating safely and independently
    • The patient is able to eat and sleep without significant episodes of dyspnoea
  • All patients discharged home should have
    • A written plan for management of there exacerbation including medications use and information on COPD (see link http://lungfoundation.com.au/wp-content/uploads/2014/02/LFA-COPD-Action-Plan-Editable-pdf.pdf)
    • Scripts for bronchodilators, prednisolone and antibiotics (if indicated)
    • A letter to there GP. Advise to see their GP within 7 days.
    • Consideration of increased home supports (liaise with CCT and social work)
  • The majority of patients will require admission under either Respiratory medicine (if already known to the team or isolated respiratory problem) or AAU (minority). Indications for hospitalization are;2
    • Marked increase in intensity of symptoms
    • An acute exacerbation plus one or more of the following
      • Inadequate response to ambulatory treatment
      • Inability to walk between rooms when previously able
      • Inability to eat or sleep because of dyspnoea
      • Cannot manage at home even with home care resources
      • High risk comorbidity condition – eg pneumonia or right heart failure
      • Altered mental state
      • Worsening hypoxia
      • New arrhythmia
    • Patients commenced on BIPAP can either be;
      • transferred to Respiratory ward, ICU or NOSA (majority)
      • weaned in ED, then to Respiratory or Medical ward (minority)
    • Intubated patients are transferred to ICU

 

 

References

  1. Rabe K, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management and prevention pf chronic obstructive pulmonary disease: GOLD executive summary. Am J Respi Crit Care Med. 2007;176(6):532-555.
  2. Australian Lung Foundation, Thoracic Society of Australia and New Zealand. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease 2008.
  3. Kelly A, Kyle E, McAlpine R. Venous pCO(2) and pH can be used to screen for significant hypercarbia in emergency patients with acute respiratory disease. J Emerg Med. 2002;22(1):15-19.
  1. Kelly A, Kerr D, Middleton P. Validation of venous pCO2 to screen for arterial hypercarbia in patients with chronic obstructive airways disease. J Emerg Med. 2005;28(4):377-379.
  1. Durrington H, Flubacher M, Ramsay C, Howard L, Harrison B. Initial oxygen management in patients with an exacerbation of chronic obstructive pulmonary disease. QJM. 2005;98(7):499-504.
  1. Plant P, Owen J, Elliott M. One year period prevalence study of respiratory acidosis in acute exacerbations of COPD: implications for the provision of non-invasive ventilation and oxygen administration. Thorax. 2000;55(7):550-554.
  1. McCrory D, Brown C. Inhaled short-acting beta2-agonists versus ipratropium for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2001(2):CD002984.
  2. McCrory D, Brown C. Anti-cholinergic bronchodilators versus beta2- sympathomimetic agents for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002(4):CD003900.
  1. Singh J, Palda V, Stanbrook M, Chapman K. Corticosteroid therapy for patients with acute exacerbations of chronic obstructive pulmonary disease: a systematic review. Arch Intern Med. 2002;162(22):2527-2536.
  2. Ram F, Rodriguez-Roisin R, Granados-Navarrete A, Garcia-Aymerich J, Barnes N. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006(2):CD004403.
  3. Gruber P, Swadron S. The acute presentation of chronic obstructive pulmonary disease in the emergency department: A challenging oxymoron. Emer Med Practice. 2008;10(11).

 
 

Date implemented – 08/2015
Revision date – 08/2018
Authors – Michael Baker, Fiona Lake (Respiratory)

 
 

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