The Assessment and Management of Acute Exacerbation of COPD in Secondary Care

If you have identified a patient as having an acute exacerbation of COPD:

Basic investigations

Chest X-ray, ABG, ECG and routine bloods, sputum cultures if the patient is productive of sputum and blood cultures if the patient is pyrexic.

Main management points:

In the absence of significant contraindications prescribe oral Prednislone 30mg for 5 days.

If you think the exacerbation is infective follow antimicrobial advice:

https://tam.nhsh.scot/for-healthcare-professionals/antimicrobial-guidance/respiratory-tract-lower/copd-acute-infective-exacerbation/

In addition prescribe nebulised or inhaled bronchodilators depending on symptom severity (most hospitalised patients with COPD will need nebulised therapy for the initial period of treatment, usually prescribed regularly eg. four times a day, in addition to as required):

• Generally we recommend 5mg nebulised salbutamol and 500 micrograms ipatropium
• If a person with COPD is hypercapnic or acidotic the nebuliser should be driven by compressed air rather than oxygen (to avoid worsening hypercapnia). This should be specified in the prescription. If oxygen therapy is needed, administer it simultaneously by nasal cannulae.
• If patient is on a LAMA (example inhalers would include trelegy ellipta, incruse ellipta, anora elllipta, trimbow, spiolto or spiriva) then do not prescribe regular ipatropium nebulisers and these patients should be continued on their usual inhaler.
• Ideally a mouthpiece rather than face mask should be used for nebulised ipatropium due to potential for eye complications

Oxygen Therapy

• Aim for 88-92% using venturi masks to deliver controlled oxygen therapy until you have an ABG result
• If the ABG shows hypercapnia, or a high bicarbonate level suggesting chronic CO2 retention, then aim for 88-92%
• If the patient had saturations before they were unwell <94%, then they should also be aimed 88-92%
• If they have a normal CO2, then you can aim 94-98%
• If they are hypercapnic and acidotic despite optimal medical therapy then the patient should have senior medical review for consideration of NIV, which should be delivered in a level 2 area

Discharge

We generally recommend that patients are off nebulised bronchodilators for 24 hours before discharge. There are a number of other interventions which should be considered at the time of discharge, ideally with delivery of a COPD discharge bundle. These interventions should include:

• Optimising their regular inhaled maintenance therapies and reviewing inhaler technique. If there has been an escalation in symptoms outwith the time they have had an acute exacerbation, or if they are having recurrent exacerbations consider if there is a need to change their regular inhaled therapy. See “Inhaled Therapy for COPD” for a clearer understanding of the different inhalers and options.
• Considering what follow up the patient requires (if any). All discharges should be referred to the community respiratory team (nhsh.communityrespiratoryteam@nhs.scot). If a patient is having frequent exacerbations then community support may help optimise their care and may provide the opportunity to have anticipatory care plan discussions.
• Consider whether smoking cessation referral is required and discuss this with the patient. Smoking cessation guidelines can be found here: https://tam.nhsh.scot/for-healthcare-professionals/therapeutic-guidelines/mental-health/smoking-cessation/
• Consider if referral to pulmonary rehabilitation will be beneficial for the patient, for more information: https://tam.nhsh.scot/for-healthcare-professionals/therapeutic-guidelines/respiratory/pulmonary-rehabilitation/
• Offer the patient access to patient education and self management resources:
  • MyLungsMyLife
  • British Lung Foundation
  • Chest Heart and Stroke Scotland
  • Self-management plans 'Traffic Lights for COPD' are free to order or can be printed 
  • Use self-management checklist as an aide-memoire

The most recent guideline which covers the management of COPD exacerbation in the UK is the 2018 NICE guideline Chronic obstructive pulmonary disease in over 16s: diagnosis and management  which can be accessed at: 

https://www.nice.org.uk/guidance/ng115

Differentiation of Chronic Breathlessness: Common Presentations of Asthma, COPD & Heart Failure

• Any history of childhood respiratory conditions or any diagnosis of adult asthma
• Frequency of exacerbations
• Occupational history
• CAT score 
• Oxygen saturations by pulse oximetry
• Degree of airflow obstruction - post-bronchodilator FEV1 (absolute figure and percentage predicted or normal range) - send patient spirometry with referral
• Full blood count
• Eosinophil count (for COPD less than 0.3x10⁹/L)
• Chest X-ray if not done within the last year

Consider a diagnosis of COPD in patients who are:

• 35 years of age and over
• Smokers or ex-smokers
• Have any of the following symptoms
  • Breathlessness on exertion
  • Chronic cough
  • Regular sputum production
  • Frequent winter bronchitis or chest infections
  • Wheeze

Pose bronchodilator spirometry showing FEV1/FVC of 0.70 is essential for diagnosis of airflow obstruction.

Widely used for its impactful message about the comparative value of interventions for COPD that rebalances the value accorded to flu vaccination, stop smoking as a treatment, pulmonary rehabilitation, inhaled medicines and telemedicine using cost per quality adjusted life year (QALY).
http://thorax.bmj.com/content/69/11.cover-expansion

1. Promote a self-management approach at every stage. Provide the following written information and support tools.
   • MyLungsMyLife
   • British Lung Foundation
   • Chest Heart and Stroke Scotland
   • Self-management plans 'Traffic Lights for COPD' are free to order or can be printed 
   • Use self-management checklist as an aide-memoire
2. Vaccination
   All patients with COPD are to receive an annual flu vaccine and a pneumonococcal according to the Green Book Guide - immunisation against infectious diseases.  
3. Smoking cessation
   Encouraging patients with COPD to stop smoking is one of the most important components of their management. All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity.
   For professionals to effectively give brief intervention advice see: Tool
   See smoking cessation guidelines
4. Offer pulmonaryrehabilitation
5. Promote effective inhaled therapy

Ask the patient to demonstrate inhaler technique at every opportunity.

See RightBreathewebsite for inhaler technique videos and device information.
Contact the Community Respiratory Team for advice on inhaler training devices. nhsh.communityrespiratoryteam@nhs.scot

Choose a drug based on the person's symptomatic response and preference, the drug's side effects, potential to reduce exacerbations and cost.

Highland Formulary Respiratory section

Step down of ICS

It may be appropriate in some cases to consider stepping down inhaled corticosteroid treatment, particularly in patients with previous pneumonia and those who are predominantly symptomatic but not exacerbating. This should be done cautiously, using the NHS Highland Guideline below for the withdrawal of Inhaled Corticosteroids (ICS) in patients with COPD.

When discontinuing ICS, it may be worthwhile checking blood eosinophil (provided not on oral /L corticosteroids). An eosinophil count <0.3x10⁹ /L adds confidence that ICS may not be required.

Withdrawing ICS

Low/medium dose ICS 

• STOP
• Consider LAMA/LABA for dual bronchodilation
• Monitor

High dose ICS

• Switch to low/medium strength
• Continue/consider LAMA/LABA for dual bronchodilation
• Review 4-8 weeks
• If stable or improved consider stopping low/medium strength ICS

Monitor off ICS

If increased exacerbations reconsider need for ICS and consider undiagnosed asthma

Theophylline 

• Offer only after trials of short and long acting bronchodilators or to people who cannot use inhaled therapy.
• Theophylline can be used in combination with beta 2 agonists and muscarinic antagonists.
• Take care when prescribing to older people because of pharmacokinetics, co-morbidities and interactions with other medications.
• Reduce theophylline dose if macrolide or flouroquinolone antibiotics (or other drugs known to interact) are prescribed to treat an exacerbation.
• Review at least annually.

Mucolytic therapy

• Consider in people with a chronic, productive cough to reduce sputum viscosity.
• Review in 4 weeks and continue use if symptoms improve or stop if no benefit.
• Do not routinely use to prevent exacerbations. 

Corticosteroids

• These are used in the management of acute exacerbation. Maintenance use of oral corticosteroid therapy in COPD is not normally recommended
• Some people with advanced COPD may need maintenance oral corticosteroids if treatment cannot be stopped after an exacerbation. If considering maintenance refer to respiratory specialist.
• Maintenance steroid doses should be kept as low as possible. In patients requiring repeated courses of corticosteroids and those requiring long-term maintenance therapy, monitor for adverse effects and consider gastro and bone protection as appropriate.

Anti-tussives are not recommended.

The frequency of exacerbations should be reduced by:

• Vaccinations
• Stopping smoking
• Completing pulmonary rehabilitation
• Appropriate use of inhalers

The impact of exacerbations should be minimised by:

• Giving self-management advice on early recognition and responding promptly to the symptoms of an exacerbation
• Starting appropriate treatment with oral steroids and/or antibiotics
• Considering a sputum culture to guide antibiotic therapy in patients who have frequent exacerbation

Management of exacerbations

1. Increase dose or frequency of short acting beta agonist (SABA) to relieve breathlessness. Ensure patients are encouraged to use a spacer to deliver maximum dose to the lungs.
2. Start oral corticosteroids for hospitalised patients and those in the community where breathlessness is interfering with daily activities

→ prednisolone 30mg once daily for 5 days
→ consider GI and bone protection (particularly if 3-4 courses annually)
→ doses of up to 40mg daily for up to three weeks do not usually need to be tapered down, however be aware if patients have had multiple recent courses, they may require a gradual dose reduction, and some patients require a long term maintenance dose of oral corticosteroid.

3. Start antibiotics if there is purulent sputum and increased breathlessness and/or increased sputum volume. See Highland Formulary for detailed antimicrobial information.
4. For exacerbating patients, review need for rescue medications
   

Referral for advice, specialist investigations or treatment may be appropriate at any stage of disease, not just for people who are severely disabled.

Possible reasons for referral include:

• Diagnostic uncertainty
• Suspected severe COPD
• The individual requests a second opinion
• Onset of cor pulmonale
• Assessment for oxygen therapy, long-term nebuliser therapy or oral corticosteroid therapy
• Bullous lung disease
• Rapid decline in FEV1
• Assessment for lung volume reduction surgery or lung transplantation
• Dysfunctional breathing
• Onset of symptoms under 40 years or a family history of alpha-1 antitrypsin deficiency
• Symptoms disproportionate to lung function deficit
• Frequent infections
• Haemoptysis

Send patient spirometry with referral

How to refer

• Respiratory consultant via SCI Gateway
• Community Respiratory Team via SCI Gateway or nhsh.communityrespiratoryteam@nhs.scot

Palliative Care

A palliative approach should be considered in the care of those individuals who

• Have persistent severe symptoms despite optimal therapy
• Have had  an acute episode requiring non-invasive ventilation
• Have cor pulmonale
• Are on LTOT (Long Term Oxygen Therapy)

SPICT tool

A palliative approach includes holistic assessment and regular review along with consideration of referral to specialist palliative care services for complex symptom control and psychospiritual support.

Palliative Care Guidelines

Anticipatory Care

Requires practitioners to adopt a thinking ahead approach that allows them to work with patients and those close to them to set and achieve goals that will ensure the right thing is being done, at the right time, by the right person(s) with the right outcome.

ACPA (Anticipatory Care Patient Alert)
Long Term Conditions ACPA Form

Oxygen 

Managing Breathlessness
Handheld fan
Breathing techniques
Positions
Thinking
Relaxation
Energy levels