COPD NICE - Exacerbations

Primary Care Respiratory Society UK (PCRS-UK)

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Exacerbations of COPD

Definition
An exacerbation of COPD is characterised by

Sustained worsening of the patient's symptoms from their usual stable state
symptoms beyond normal day-to-day variations
Acute onset
Symptoms which require treatment modification

The main symptoms are increased breathlessness, cough, sputum production, sputum purulence and general mailise/fatigue

COPD exacerbations are linked to compromised quality of life for the patient. Hospital admissions for exacerbations of COPD are also a marker for worsening prognosis.

Management of exacerbations
Treatment should be started as early as possible and includes:-

Take maximal bronchodilator therapy (e.g. salbutamol 800mcg 3hrly delivered via MDI and spacer device)
Oral steroids (30mg prednisolone for 7-14 days) if symptoms persist despite adequate bronchodilators
Antibiotics (amoxycillin 500mg t.d.s. or clarithromycin 500mg b.d.) if sputum goes yellow or green. Refer to local guidance for prescribing advice and duration of treatment
Patients should be taught to recognise an exacerbation and provided with access to treatment to implement early management
Pulse oximetry should be measured and 24%-28% oxygen delivered if necessary to keep saturation between 88%-92%

Indications for in-patient assessment
Patients with the following symptoms should be referred for in-patient assessment including chest x-ray, blood gases and ECG:

Worsening hypoxaemia
Unremitting severe breathlessness
Confusion, drowsinesss (may indicate hypercapnia)
New onset of peripheral oedeam or cyanosis
Chest pain and fever (may indicate other pathology e.g. pneumonia)

Emergency oxygen may be given to hypoxic patients pending transfer to hospital with the aim of raising oxygen saturation to a target range of 88-92% (but no higher since excess oxygen may cause carbon dioxide retention)

COPD Self-management
Following an exacerbation or hospital admission patients should be reviewed in the practice to ensure optimal pharmacotherapy and review of self-management advice.

Sample COPD Action Plan

The PCRS-UK is grateful to Dr Kevin Gruffydd-Jones, Dr John Haughney, Dr Rupert Jones and Dr Noel O'Kelly as authors of the PCRS-UK booklet, Diagnosis and Management of COPD in Primary Care, on which this quick reference guide is based. This Quick Reference Guide has been supported by an educational grant from Allen & Hanburys, the specialist respiratory division of GlaxoSmithKline. The views expressed in this guide is not necessarily those of either the sponsor or the Primary Care Respiratory Society UK (PCRS-UK). © PCRS-UK

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