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.
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.
- 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’
- 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
- 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 to delegate 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
- Your assessment and management should be documented in the patient’s notes
- 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
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.
- 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.
Can the patient talk?
- Airway is patent; consider checking the mouth for signs of impending obstruction, then move on to breathing assessment
- 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)?
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)
- 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)
Generally, aim for oxygen saturations of 88-92% until you have established whether the patient is a CO2 retainer.
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?
- 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)?
- Tracheal deviation may imply a tension pneumothorax
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?
It is likely that you will encounter a breathing problem, and therefore you need to initiate management before moving onto circulation, disability, and exposure etc.
- 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
- 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
- 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
- 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
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.
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)
- 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 (FiO2) – 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 & PaCO2:
- 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
- Some patients with severe COPD will have chronic hypercapnia (chronically raised CO2) 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
- 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
- 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
- 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
- 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.
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.
- 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)?
- 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)
If higher or lower than normal parameters, consider infection as a cause
- Are there signs that suggest right heart failure (cor pulmonale)?
- e.g. right ventricular heave, raised JVP, or peripheral oedema
Gain IV access to allow administration of antibiotics and fluids.
You should send a set of blood tests to elicit the underlying cause of the COPD 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 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
If the patient has signs of hypovolaemia or shock they will need to be resuscitated with IV fluids.
All patient presenting with tachycardia should have a 12 lead ECG (see ECG interpretation).
- 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.
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
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.
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.
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 your ABCDE assessment clearly, including examination, observations, investigations, interventions, and patient response/changing condition. Write down any pertinent details from your history-taking.
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?
The next team of doctors on shift should be made aware of any patient in their department who has become acutely unwell.