COPD | Acute Management | ABCDE

geekymedics.com/management-of-an-acute-exacerbation-of-copd/

Grace Mckay April 4, 2018

An acute exacerbation of chronic obstructive pulmonary disease (COPD) is a potentially

life-threatening condition which needs to be rapidly recognised, effectively managed, and escalated
to appropriate senior staff. This guide gives an overview of the recognition and immediate
management of exacerbations of COPD using an ABCDE approach.

This guide has been created to assist students in preparing for emergency simulation sessions as part
of their training. It is not intended to be relied upon for patient care.

A bit of background

What is COPD?
COPD is a respiratory disease characterised by airflow obstruction that is not fully reversible. The
airflow obstruction is present because of damage to the airway and parenchyma, secondary to
chronic inflammation. COPD normally results from chronic exposure to tobacco smoke, however
occupational exposure and genetic abnormalities may also contribute.

What is an exacerbation of COPD?

An ‘exacerbation’ of COPD is a sustained deterioration in a patient’s respiratory symptoms beyond
their normal day-to-day variability. This worsening occurs acutely and will normally require
additional medical therapy.

What can trigger an exacerbation of COPD?

The most common triggers for an exacerbation of COPD are respiratory tract infections.

In the community, Streptococcus pneumoniae and Haemophilus influenzae are the most common
bacterial culprits. Viral causes include rhinoviruses, influenza and respiratory syncytial virus
(RSV). Pollutants may also trigger an exacerbation.

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Why is it important to learn about?
COPD is very common. Recent data estimates that there are 3 million people living with COPD in
the UK, only 900,000 of whom have been diagnosed. This means that you are very likely to meet
and care for patients with COPD when you start work as a doctor.

In addition, patients presenting with an exacerbation of COPD may be very unwell and therefore it is
important to recognise, manage and escalate their care promptly.

Clinical features

Symptoms
Worsening breathlessness
Productive cough – the patient may have noticed a change in the volume, consistency or
colour of their sputum
Acute confusion
Malaise – a general feeling of being ‘unwell’
Fatigue/lethargy
Increased wheeze – due to obstruction of alveoli and bronchi
Coryzal symptoms – eg. ‘cold’, ‘sore throat’ or ‘runny nose’
Haemoptysis – coughing up blood
Chest tightness or pain
Reduced exercise tolerance
Worsening peripheral oedema

Signs
Tachycardia
Tachypnoea
Hypoxia
Cyanosis – bluish discolouration indicating hypoxia
Reduced level of consciousness

Tips before you begin

Treat all problems as you find them
Re-assess regularly and after every intervention to see if your management is effective
Make use of the team around you todelegate tasks where appropriate
All critically unwell patients should have continuous monitoring equipment attached for
accurate observations
If you need senior input for your patient,call for help early using SBARR
Review results (e.g. laboratory investigations) as they become available
Make use of guidelines and algorithms for managing specific situations
Medications or fluids will need to be prescribed
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 Your assessment and management should be documented in the patient’s notes

Initial steps

Introduction
Wash your hands
Introduce yourself to whoever has requested a review of the patient
Introduce yourself to the patient
Ask the patient how they are
Ask if they are in any pain

Inspection
Perform a quick general inspection of the patient to get a sense of how unwell they
are:

Check consciousness level using AVPU

How does the patient look?
Watch the patient breathing from the end of the bed
Quickly assess respiratory effort (respiratory rate and use of accessory muscles) and
look for signs of hypoxia such as central cyanosis
What is around the bedside?
Look for inhalers, nebulisers, oxygen tubing, sputum cups etc.

Preparation
Make sure the patient notes, observation chart and medication chart are on hand (this should
not delay your immediate clinical assessment)
Ask for another clinical member of staff to assist you if possible

If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per
resuscitation guidelines.

Airway

Assessment

Can the patient talk?

YES:

Airway is patent; consider checking the mouth for signs of impending obstruction, then move
on to breathing assessment

NO:

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 Look for signs of airway compromise (e.g. see-saw breathing, use of accessory muscles,
diminished breath sounds, added sounds)
Is the patient cyanosed?
Open the mouth and inspect: is there anything obviously compromising the airway (e.g. large
swollen tongue, thick secretions)?

Intervention
In any case of airway obstruction, seek immediate expert help from an anaesthetist. You may need
the crash team. In the meantime, you can perform some basic airway manoeuvres to help maintain
the airway.

Maintain the airway whilst awaiting senior input

1. Perform the head tilt, chin lift manoeuvre

2. If noisy breathing persists try a jaw thrust

3. If airway still appears compromised use an airway adjunct:

Insert an oropharyngeal airway (Guedel) or a laryngeal mask airway (LMA) only if

unconscious (as otherwise may gag/aspirate)
Alternatively, use a nasopharyngeal airway (better tolerated if the patient is partially
conscious)

Breathing

Assessment

Respiratory rate
Tachypnoea (commonly seen in exacerbations of COPD)
Bradypnoea (low respiratory rate or normal respiratory rate in the context of hypoxia is a sign
of impending respiratory failure and need for urgent critical care review)

Oxygen saturation
Generally, aim for oxygen saturations of 88-92% until you have established whether the patient is a
CO2 retainer.

Look
Watch the patient breathing from the end of the bed:

Are they working hard to breathe (dyspnoea)?

Are they pursing their lips to force air out or using their accessory muscles at
rest?
Do they look distressed?
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 Do their lips look blue (cyanosis)?

Chest wall movement – assess chest wall rise, is it symmetrical?

Asymmetrical movement may indicate a collapsed lung or consolidation
Any scars on the chest wall to indicate previous relevant surgery such as a chest drain or
lobectomy (don’t spend too long looking)?

Feel
Tracheal position:

Tracheal deviation may imply a tension pneumothorax

Listen
Auscultate lungs, assess for air entry bilaterally and listen for added sounds:

Is the patient wheezing on expiration?

Can you hear coarse crackles that may indicate an infection?

Intervention
It is likely that you will encounter abreathing problem, and therefore you need to initiate
management before moving onto circulation, disability, and exposure etc.

Oxygen
Sit the patient upright
If hypoxic, administer oxygen and titrate to 88-92%
This may be via nasal cannulae at 2 litres/minute, however, if the patient is acutely
unwell then 15 litres/minute via a non-rebreather mask may be appropriate

Salbutamol
Prescribe the patient a dose of a short-acting bronchodilator (e.g. salbutamol 5mg)
In the acute hospital setting, the patient will most likely require this delivered via a nebuliser
Prescribe the salbutamol on the ‘acute/stat’ section of the drug chart, and ensure that you
inform the nursing staff that you want the nebuliser driven by compressed air, not oxygen (to
avoid worsening hypercapnia)
If the patient is also hypoxic, then oxygen therapy can be administered simultaneously via a
nasal cannulae underneath the nebuliser

Ipratropium
Nebulised antimuscarinics such as ipratropium bromide 500 micrograms should be
used if patients are not responding to salbutamol
Prescribe the therapy on the ‘acute/stat’ part of the drug chart
Ipratropium bromide can be given with salbutamol in the same nebuliser
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Steroids
Oral corticosteroids should be used in all patients admitted to hospital with an exacerbation of
COPD
Local guidelines differ, but prednisolone 30 mg orally once a day for 7 to 14 days is
recommended by NICE

Other
If the above interventions fail to improve breathing you should escalate the patient’s
care to senior medical staff:

Consideration of non-invasive ventilation (NIV) for persistent hypercapnic respiratory

failure will require senior specialist input and likely admission to the intensive care unit.
Likewise, respiratory stimulants and intravenous theophylline should only be used if
there is an inadequate response to nebulised bronchodilators. Senior input is strongly
advised.

Investigations

Arterial blood gas

This will quickly provide you with information about the patient’s current physiological state
There are many systematic ways to review an ABG (see ABG interpretation)

PaO2:

A normal PaO2 on room air should be >10 kPa (75 – 100 mmHg)
If the patient is receiving supplemental oxygen then the PaO2 should be roughly 10 kPa less
than the inspired oxygen concentration (FiO 2) – for example, if the patient is on 35% oxygen
then the FiO2 should be approximately 25 kPa
When interpreting an arterial blood gas it is important that you know the inspired oxygen
concentration
If the patient is hypoxic, then increase the oxygen and consider calling for help

pH & PaCO 2:

CO2 binds with H20 in the blood and forms carbonic acid
If a patient is retaining carbon dioxide, then the pH decreases (blood becomes more acidotic)
A low pH with a raised PaCO2 suggests a respiratory acidosis
A persistent respiratory acidosis may require the use of non-invasive ventilation

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HCO3-:

Some patients with severe COPD will have chronic hypercapnia (chronically raised CO) 2
which can make ABG interpretation more complicated when they are acutely unwell, as it can
be difficult to establish whether their raised CO2 is acute, chronic or acute on chronic in
nature
In the setting of chronic hypercapnia, the bicarbonate (HCO3-) rises to ‘mop up’ the acidic
effect of carbonic acid and neutralise the pH
As metabolic compensation takes several days to occur (because it requires the kidneys to alter
their production of HCO3-), a raised HCO3- in the acute context suggests that this patient has
chronic hypercapnia with a metabolic compensation

Lactate:

A raised lactate indicates anaerobic metabolism secondary to reduced end-organ perfusion

In this scenario, if the lactate is raised then consider sepsis as your main differential diagnosis

NOTE:

A patient presenting with an acute exacerbation of COPD will likely require serial ABGs to
monitor their response to oxygen therapy
After any change in inspired oxygen concentrations, consider repeating the ABG

Chest x-ray
If the patient is acutely unwell then a portable CXR will need to be arranged
If someone else can arrange this imaging whilst you are assessing the patient, this will
expedite their care
Look for signs of infection (also assess for a pneumothorax and signs of pulmonary oedema)
See our CXR interpretation guide here

Sputum culture
This is not an urgent investigation, but if the patient is coughing up a large amount of sputum
then ask for a sample to be sent for microbiology, culture and sensitivity. This information can
be useful later to understand the causative organism and its antibiotic sensitivities.

Reassess
At this point following initial management, it is important to reassess the patient. If the respiratory
parameters have NOT improved (i.e the patient is still hypoxic and/or dyspnoeic despite treatment,
or even worse they are becoming drowsy and fatigued) then you must escalate to a senior for urgent
review and advice.

If the patient is stable then move on to circulation.

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Circulation

Assessment

Heart rate
Is the patient tachycardic?
This may indicate hypercapnia, infection, pain or anxiety
Note that beta-agonists (e.g. salbutamol) can cause tachycardia
Is the pulse regular or irregular?
Assess the pulse character
Is it thready and weak (sepsis, hypovolemia) or bounding (CO2 retention)?

Blood pressure
Hypotension may be a sign of sepsis
Hypertension may be due to an acute stress response or undertreated chronic hypertension
Make sure you ask the patient whether they take any medication for their blood
pressure

Capillary refill time

Normal: < 2 seconds
If prolonged may be due to hypovolaemia (secondary to sepsis)

Temperature
If higher or lower than normal parameters, consider infection as a cause

Examination
Are there signs that suggest right heart failure (cor pulmonale)?
e.g. right ventricular heave, raised JVP, or peripheral oedema

Intervention

IV access
Gain IV access to allow administration of antibiotics and fluids.

Blood tests
You should send a set of blood tests to elicit the underlying cause of the COPD
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exacerbation and assess any associated biochemical disturbances:

Full blood count (FBC) – to assess for raised white cells and anaemia
Urea and electrolytes (U&Es) – to assess for acute kidney injury and electrolyte disturbances
C-reactive protein – to assess for evidence of infection
Lactate – to assess for evidence of sepsis
Glucose – part of the sepsis screen
Blood cultures – if pyrexial and sepsis is suspected

Antibiotics
Antibiotics should only be used to treat exacerbations of COPD associated with a history of
increased purulent sputum production or other clinical features suggestive of pneumonia such
as fever, raised inflammatory markers and signs of consolidation on chest X-ray (CXR)
Patients presenting without these features do not need antibiotic therapy
Prescribe antibiotics in keeping with local guidelines

IV fluids
If the patient has signs of hypovolaemia or shock they will need to be resuscitated with IV fluids.

ECG
All patient presenting with tachycardia should have a 12 lead ECG (see ECG interpretation).

Disability

Assess GCS
Assess whether the patient is acutely confused or has a reduced level of consciousness
(possible causes include sepsis and CO2 retention)
If the patient is beginning to tire and appears drowsy, seek urgent senior input

Check capillary blood glucose

Hypoglycaemia may be contributing to a reduced level of consciousness

N.B: Alert a senior immediately if you have any concerns about the consciousness level of a patient.
A GCS of 8 or below warrants urgent expert help from an anaesthetist. The crash team may be
needed. Be very cautious of a patient not maintaining their own airway if the GCS is reduced.

Exposure

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The ‘everything else’ part of your assessment will involve exposing the patient and ensuring that you
are performing a thorough general inspection. Significant features to look for in an exacerbation of
COPD include:

Peripheral cyanosis
Asterixis – CO2 retention flap
Tremor – suggestive of bronchodilator therapy
Abdomen – any pain or distension?
Calves – any clinical sign of deep vein thrombosis (unilateral red swollen and painful leg)
Pulmonary embolism may be a differential for an acutely breathless and hypoxic patient
Rashes and angioedema – consider anaphylaxis

Reasses ABCDE
It is essential to continually reassess ABCDE and treat issues as you encounter them. This allows
continual reassessment of the response to treatment and early recognition of any deterioration.

If the patient does not respond to treatment or deteriorates, critical care should be involved as soon
as possible.

Next steps
Well done! You’ve stabilised the patient and they’re doing much better. Just a few more things to
do…

Take a history
Take a more detailed history of what has happened and how the patient has been. Involve staff or
family members as appropriate.

It is particularly important to ascertain whether the patient uses home oxygen, nebulisers or non-
invasive ventilation. It is also pertinent to ask whether the patient has required HDU admission
previously for NIV and whether they would be willing to try it again if indicated. This may sound like
a paradoxical question, however, some patients who have experienced NIV would not want it again.

Check out our history taking guides here

Review
Review the patient’s notes, observations, fluid charts, and any investigation findings. Double check
the medications you have just prescribed, and any routine medications the patient is taking.

Document
Document your ABCDE assessment clearly, including examination, observations, investigations,
interventions, and patient response/changing condition. Write down any pertinent details from your
history-taking.
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See documentation guide

Clarify ceiling of care and resuscitation preferences

This may go beyond the scope of a simulation scenario, however, in practice, a
resuscitation/escalation discussion should be considered on every admission to hospital.

Discuss with seniors

If a senior doctor hasn’t already been involved, it is important to contact them and make them aware
of the unwell patient. As a junior doctor, it would be appropriate to give an SBARR handover
outlining your assessment and actions, and to discuss the following:

Are any further assessments or interventions required?

Does the patient need a referral to HDU/ICU?
Should they be referred for a review by a speciality doctor?
Should any changes be implemented to the management of any underlying conditions?

Handover
The next team of doctors on shift should be made aware of any patient in their department who has
become acutely unwell.

Further reading
https://www.nice.org.uk/guidance/NG115
http://bestpractice.bmj.com/topics/en-gb/8
https://cks.nice.org.uk/chronic-obstructive-pulmonary-disease#!scenario:1
http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf
https://www.rcemlearning.co.uk/references/chronic-obstructive-pulmonary-disease/
https://www.aafp.org/afp/2001/0815/p603.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645331/
https://www.atsjournals.org/doi/full/10.1513/pats.200707-088ET
https://patient.info/doctor/acute-exacerbations-of-copd

Editor

Andrew Gowland

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