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Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)

Patient with known or provisional diagnosis of COPD)

Use Management table to decide where to manage exacerbation?

Factors to consider when
deciding where to manage
exacerbations

 Treat at home Treat in Hospital
Able to cope at home Yes No
Breathlessness Mild Severe
General condition Good Poor/deteriorating
Level of activity Good Poor/confined to bed
Cyanosis No Yes
Worsening peripheral oedema No Yes
Level of conciousness Normal Impaired
Already receiving LTOT No Yes
Social circumstances Good Living Alone/Not Coping
Rapid rate of onset No Yes

Significant comorbidity
(particularly cardiac
disease and
insulin-dependant
diabetes)

 No Yes
SaO2 < 90% No Yes
Change on chest radiograph No Present
Arterial pH level ≥ 7.35 < 7.35
Arterial PaO2 ≥ 7 kPa < 7 kPa

 

HOSPITAL

History/Examination

inc. baseline observations (HR, BP, Temp, Resp
Rate, Spo2, EWS, AVPU)

Essential Investigations:

  • Chest X-Ray
  • ECG recorded
  • FBC, U&E’s, CRP
  • Theophylline level (if person is on theophylline)
  • Blood cultures (if pyrexial)

Other Investigations to consider:

  • Arterial blood gas tensions measured and the inspired oxygen concentration recorded. Oxygen sats recorded and targeted oxygen prescribed if required
  • Sputum Sample and culture for sensitivity

    • Any of the following Present?

    • Cyanosis
    • Unable to talk full sentences
    • Confusion/↓GCS
    • Peri-arrest
    • Chest Pain

    Yes

    If patient in A&E transfer to Resus

    Inform Senior Doctor and put patient on Medical Therapy Pathway

    Medical Therapy Pathway

    No

    Blood Gas pH <7.35 pCO2>6.0? Yes

    Put patient on Medical Therapy Pathway

    Medical Therapy Pathway

    If patient improves:

    If patient in A&E transfer to AMU

    Consider referral to Physiotherapy

    Preferably transfer to Ward 23/24 as soon as patient is stable

    Follow Monitoring Recovery and Early Assisted Discharge Pathway

    Monitoring Recovery and EAD Pathway

    If patient does not improve:

    Repeat blood gas within 30-60mins following change in oxygen flow until target achieved OR clinically appropriate

     

    Blood Gas pH <7.35 pCO2>6.0? No

    Reduce Oxygen flow if target achieved (88-92%) OR pH<7.35 pCO2>6

    Yes

    Put patient on Medical Therapy Pathway

    Medical Therapy Pathway

    No

    If patient in A&E transfer to Resus

    Inform Senior Doctor and put patient on Medical Therapy Pathway

    Medical Therapy Pathway

    Repeat Blood gas within 30-60 minutes following change in oxygen flow until target achieved OR clinically appropriate

    Blood Gas pH <7.35 pCO2>6.0? Yes

    Put patient on Medical Therapy Pathway

    Medical Therapy Pathway

    Blood Gas pH <7.35 pCO2>6.0? No

    Reduce Oxygen flow if target achieved (88-92%) OR pH<7.35 pCO2>6.0

    No

    Consider NIV. Complete Prescription Chart for Acute NIV

    Follow Non-Invasive Ventilation (NIV) in Treatment of Acute Exacerbation of Chronic Obstgructive Pulmonary Disease (COPD) and other Conditions Trust Protocol.

    AT HOME

    TTO Discharge letter to refer to GP/Community Matron for review. GP/Community Matron will:

    • Establish on optimal therapy
    • Arrange a multidisciplinary assessment if necessary
    • Give clear instructions about correct use of medications (including oxygen) and stopping corticosteroid therapy
    • Ensure patients are aware of the optimum duration of treatment and the adverse effects of prolonged oral corticosteroid therapy
    • Undertake pulse oximetry
    • Sputum culture is not normally recommended unless recurrent steroids and antibiotics.