COPD | Acute Management | ABCDE

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This guide provides an overview of the recognition and immediate management of chronic obstructive pulmonary disease (COPD) using an ABCDE approach.

The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:

• Airway
• Breathing
• Circulation
• Disability
• Exposure

Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.

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.

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Background

What is COPD?

COPD is a respiratory disease characterised by airflow obstruction that is not fully reversible. Airflow obstruction occurs secondary to structural damage to the airways and parenchyma as a result of chronic inflammation. COPD is most commonly caused by chronic exposure to tobacco smoke, however, occupational exposure and genetic abnormalities may be contributory factors.

What is an exacerbation of COPD?

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

What can trigger an exacerbation of COPD?

The most common trigger for an exacerbation of COPD is respiratory tract infection. 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 can also trigger an exacerbation.

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Clinical features of COPD

Symptoms

Typical symptoms of COPD include:

• Worsening breathlessness
• Productive cough: the patient may have noticed a change in the volume, consistency or colour of their sputum.
• Malaise
• Fatigue/lethargy
• Increased wheeze: due to obstruction of alveoli and bronchi.
• Coryzal symptoms
• Haemoptysis
• Chest tightness or pain
• Peripheral oedema

Signs

Typical clinical signs of COPD include:

• Tachycardia
• Tachypnoea
• Hypoxia
• Cyanosis
• Reduced level of consciousness

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Tips before you begin

General tips for applying an ABCDE approach in an emergency setting include:

• Treat all problems as you discover them.
• Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
• Make use of the team around you by delegating tasks where appropriate.
• All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
• Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
• If you require senior input, call for help early using an appropriate SBARR handover structure.
• Review results as they become available (e.g. laboratory investigations).
• Make use of your local guidelines and algorithms in managing specific scenarios (e.g. acute asthma).
• Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff).
• Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions.

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Initial steps

Acute scenarios typically begin with a brief handover from a member of the nursing staff including the patient’s name, age, background and the reason the review has been requested.

You may be asked to review a patient with COPD due to shortness of breath and/or wheeze.

Introduction

Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.

Interaction

Introduce yourself to the patient including your name and role.

Ask how the patient is feeling as this may provide some useful information about their current symptoms.

An inability to speak in full sentences indicates significant shortness of breath.

Preparation

Make sure the patient’s notes, observation chart and prescription chart are easily accessible.

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.

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Airway

Clinical assessment

Can the patient talk?

Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.

No:

• Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
• Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.

Interventions

Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.

Head-tilt chin-lift manoeuvre

Open the patient’s airway using a head-tilt chin-lift manoeuvre:

1. Place one hand on the patient’s forehead and the other under the chin.

2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.

3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it.

Jaw thrust

If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:

1. Identify the angle of the mandible.

2. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.

3. Using your thumbs, slightly open the mouth by downward displacement of the chin.

Oropharyngeal airway (Guedel)

Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.

An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.

To insert an oropharyngeal airway:

1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.

2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.

3. Advance the airway until it lies within the pharynx.

4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.

Nasopharyngeal airway (NPA)

A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.

To insert a nasopharyngeal airway:

1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.

2. Lubricate the NPA.

3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.

4. If any obstruction is encountered, remove the tube and try the left nostril.

Other interventions

If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our anaphylaxis guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Breathing

Clinical assessment

Observations

Review the patient’s respiratory rate:

• A normal respiratory rate is between 12-20 breaths per minute.
• Tachypnoea is a common feature of COPD exacerbations and indicates significant respiratory compromise.
• Bradypnoea in the context of hypoxia is a sign of impending respiratory failure and the need for urgent critical care review.

Review the patient’s oxygen saturation (SpO₂):

• A normal SpO₂ range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO₂ retention.
• Hypoxaemia is a typical clinical feature of COPD.

See our guide to performing observations/vital signs for more details.

Inspection

Inspect the patient from the end of the bed:

• Cyanosis: bluish discolouration of the skin due to poor circulation or inadequate oxygenation of the blood.
• Shortness of breath: signs may include nasal flaring, pursed lips, use of accessory muscles, intercostal muscle recession and the tripod position.
• Cough: a productive cough with purulent sputum may indicate an infective exacerbation of COPD.
• Wheeze: a continuous, coarse, whistling sound produced in the respiratory airways during breathing associated with COPD, asthma and bronchiectasis.

Palpation

Assess the position of the patient’s trachea to identify deviation which may indicate underlying tension pneumothorax.

Locate the apex beat, which is typically located in the 5th intercostal space in the midclavicular line. A large pleural effusion, tension pneumothorax or right ventricular hypertrophy can cause a displaced apex beat.

Assess chest expansion, which may be reduced in the context of consolidation and pleural effusion.

Auscultation

Auscultate both lungs:

• Bronchial breath sounds and/or coarse crackles are associated with consolidation.
• Wheeze is a common finding in COPD patients and typically worsens during exacerbations.

Percussion

Percuss the patient’s chest to identify areas of dullness which may be associated with consolidation, lobar collapse or pleural effusion.

Investigations

Arterial blood gas

Take an ABG if indicated (e.g. low SpO₂) to quantify the degree of hypoxia.

PaO₂:

• A normal PaO₂ on room air should be greater than 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).

pH and PaCO₂:

• CO₂ binds with H₂O in the blood and forms carbonic acid. As a result, if a patient is retaining CO₂, pH decreases.
• A low pH with a raised PaCO₂ indicates the patient is failing to ventilate effectively and may require non-invasive ventilation.

HCO_3-:

• Some patients with severe COPD will have 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 (HCO_3-) rises to ‘mop up’ the acidic effect of carbonic acid and normalise the pH.
• As metabolic compensation takes several days to occur (because it requires the kidneys to alter their production of HCO_3-), a raised HCO_3- in the acute context suggests that the patient has some degree of chronic hypercapnia with metabolic compensation.

Lactate:

• A raised lactate indicates anaerobic metabolism secondary to reduced end-organ perfusion.
• Sepsis is a common cause of a raised lactate.

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 an ABG.

Chest X-ray

A chest X-ray may be useful in ruling out other respiratory diagnoses if shortness of breath is the primary issue (e.g. pneumothorax, pneumonia, pulmonary oedema). Chest X-ray should not delay the emergency management of an acute exacerbation of COPD.

See our CXR interpretation guide for more details.

Sputum culture

Ask the nursing staff to obtain a sputum sample to be sent to the microbiology lab for culture and sensitivity.

This information can be useful later to understand the causative organism and its antibiotic sensitivities.

Interventions

Oxygen

Administer oxygen to all critically unwell patients during your initial assessment. If the patient has COPD and a history of CO₂ retention you should use a venturi mask and titrate oxygen appropriately.

If the patient is conscious, sit them upright as this can also help with oxygenation.

Salbutamol

A high-dose inhaled beta-2 agonist (i.e. salbutamol) should be administered as a first-line treatment in the management of an acute exacerbation of COPD:

• Prescribe the patient a dose of a short-acting bronchodilator (e.g. salbutamol 5mg).
• Prescribe the salbutamol on the STAT section of the drug chart.
• If the patient is hypercapnic or acidotic, the nebuliser should be driven by compressed air rather than 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.

Repeat doses of salbutamol at 15-30 minute intervals or give continuous nebulised salbutamol at 5-10 mg/hour if there is an inadequate response to initial treatment.

Ipratropium bromide

Ipratropium bromide 500 micrograms should be administered if the patient does not respond adequately to nebulised salbutamol.

Ipratropium bromide can be given with salbutamol in the same nebuliser.

Steroids

All patients with an acute exacerbation of COPD should receive oral corticosteroids to reduce airway inflammation.

NICE recommends oral prednisolone 30 mg once a day for 5 days.

Other

If the above interventions fail to improve breathing you should escalate the patient’s care to senior medical staff to consider further management options including:

• Non-invasive ventilation (NIV) for persistent hypercapnic respiratory failure.
• Respiratory stimulants and intravenous theophylline.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

If the patient’s clinical condition has not improved (e.g. 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.

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Circulation

Clinical assessment

Pulse

Patients with an acute exacerbation of COPD may be tachycardic, particularly if beta-agonists have been administered.

A bounding pulse may be noted secondary to CO₂ retention.

Blood pressure

Hypotension may be present in the context of sepsis.

Capillary refill time

Capillary refill time may be prolonged in the context of sepsis.

Jugular venous pressure (JVP)

Inspect for a raised JVP which may be associated with cor pulmonale.

Palpation

Palpate the patient’s chest to feel for a ventricular heave or displaced cardiac apex both of which are associated with cor pulmonale.

Cardiac auscultation

Auscultate the patient’s praecordium to assess heart sounds:

• A gallop rhythm is a feature of congestive heart failure (e.g. secondary to cor pulmonale).

Fluid balance assessment

Calculate the patient’s fluid balance:

• Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.
• Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.

Investigations and procedures

Intravenous cannulation

Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.

See our intravenous cannulation guide for more details.

Blood tests

Collect blood tests after cannulating the patient including:

• FBC: to rule out anaemia and to look for a raised white cell count which may suggest underlying infection.
• U&Es: to assess renal function.
• CRP: to screen for evidence of infection (e.g. pneumonia).
• Blood cultures: it the patient is pyrexial.

ECG

An ECG should be performed to look for:

• evidence of acute myocardial ischaemia
• ventricular hypertrophy
• arrhythmias

An ECG should not delay the treatment of an acute exacerbation of COPD.

Interventions

Antibiotics

Antibiotics should only be used to treat exacerbations of COPD associated with a history of increased purulent sputum production or other features suggestive of pneumonia such as fever, raised inflammatory markers and signs of consolidation on chest X-ray.

Prescribe antibiotics according to local guidelines.

Intravenous fluids

Hypovolaemic patients require fluid resuscitation:

• Administer a 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over less than 15 mins.
• Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).

After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).

Repeat administration of fluid boluses up to four times (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.

Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding adequately to repeated boluses (i.e. persistent hypotension).

See our fluid prescribing guide for more details on resuscitation fluids.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Disability

Clinical assessment

Consciousness

In the context of an acute exacerbation of COPD, a patient’s consciousness level may be reduced secondary to hypoxia and/or hypercapnia.

Assess the patient’s level of consciousness using the AVPU scale:

• Alert: the patient is fully alert, although not necessarily orientated.
• Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
• Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
• Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.

If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).

Pupils

Assess the patient’s pupils:

• Inspect the size and symmetry of the patient’s pupils. Asymmetrical pupillary size may indicate intracerebral pathology.
• Assess direct and consensual pupillary responses which may reveal evidence of intracranial pathology.

Drug chart review

Review the patient’s drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives, anxiolytics).

Investigations and procedures

Blood glucose and ketones

Measure the patient’s capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g. hypoglycaemia or hyperglycaemia). 

A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).

The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.

Hypoglycaemia is defined as a plasma glucose of less than 3.0 mmol/l. In hospitalised patients, a blood glucose ≤4.0 mmol/L should be treated if the patient is symptomatic.

If the blood glucose is elevated, check ketone levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis (DKA).

See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for more details.

Imaging

Request a CT head if intracranial pathology is suspected after discussion with a senior.

See our guide on interpreting a CT head for more details.

Interventions

Maintain the airway

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. In the meantime, you should re-assess and maintain the patient’s airway as explained in the airway section of this guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Exposure

It may be necessary to expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat. 

Clinical assessment

Inspection

Review the output of the patient’s catheter and any surgical drains.

Look for alternative sources of infection (e.g. wounds, abdomen, urine).

Calves

Assess the patient’s calves for erythema, swelling and tenderness which may suggest a deep vein thrombosis.

Temperature

Assess the patient’s temperature: fever may indicate an infective cause underlying the acute exacerbation of COPD.

Investigations and procedures

Ultrasound scan or D-dimer

If a DVT is suspected, calculate the patient’s DVT Wells score to determine if an ultrasound scan or D-dimer test should be performed to confirm or exclude the presence of a DVT.

Urinalysis

If the patient has symptoms of urinary tract infection perform urinalysis to screen for evidence of infection.

See our urinalysis guide for more details.

Interventions

Blood cultures and antibiotics

If fever is identified, perform blood cultures and consider commencing antibiotics (if not already done).

Anticoagulation

If a DVT is identified, consider anticoagulation.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Reassess ABCDE

Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.

Deterioration should be recognised quickly and acted upon immediately.

Seek senior help if the patient shows no signs of improvement or if you have any concerns.

Support

You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.

You may need further help or advice from a senior staff member and you should not delay seeking help if you have concerns about your patient.

Use an effective SBARR handover to communicate the key information effectively to other medical staff.

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Next steps

Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…

Take a history

Revisit history taking to explore relevant medical history. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate.

See our history taking guides for more details.

Review

Review the patient’s notes, charts and recent investigation results.

Review the patient’s current medications and check any regular medications are prescribed appropriately.

Document

Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.

See our documentation guides for more details.

Discuss

Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.

Questions which may need to be considered include:

• Are any further assessments or interventions required?
• Does the patient need a referral to HDU/ICU?
• Does the patient need reviewing by a specialist?
• Should any changes be made to the current management of their underlying condition(s)?

Handover

The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.

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References

1. NICE guideline. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Available from: [LINK].

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