Exacerbations of COPD March 2018 | by EMauthor An exacerbation of COPD is a sustained worsening of the patient’s symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. There is no single defining symptom of an exacerbation but changes in breathlessness, cough, and sputum production are common. Assessing severity of an exacerbation of COPD For chronic symptoms see if you can categorise using Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria: •GOLD 1 - mild: FEV1≥ 80% predicted •GOLD 2 - moderate: 50% ≤ FEV1 < 80% predicted •GOLD 3 - severe: 30% ≤ FEV1 < 50% predicted •GOLD 4 - very severe: FEV1 <30% predicted. NICE guidance recommends that an exacerbation be considered severe if any of the following features are present: •Marked dyspnoea. •Tachypnoea. •Pursed lip breathing. •Use of accessory muscles at rest. •Acute confusion. •New onset cyanosis. •New onset peripheral oedema. •Marked reduction in activities of daily living. The NICE guidance recommends the following investigations are performed in all patients presenting to hospital with an exacerbation of COPD: •Chest radiograph. •Arterial blood gas with the inspired oxygen concentration recorded. •ECG (to exclude co-morbidities). •FBC. •Renal function. •Theophylline level in patients on theophylline therapy on admission. •Sputum culture. •Blood cultures if the patient is pyrexial. NICE admission criteria Treat these criteria with a dose of common sense as clearly many patients' baseline state involves frailty and dynspnea and their care will be adjusted accordingly. In short, NICE suggest admission when: •Not coping •Very breathless or cyanosed •Very oedematous •Already receiving LTOT •Sats <90 •CXR changes •pH < 7.35 or narcosed •PO2 <7 ED management of an exacerbation of COPD •Oxygen — aiming for saturations 88–92 %. •Usually nebulised salbutamol and ipratropium bromide. •Steroids— prednisolone 30 mg for 7–14 days. •Antibiotics — if history of more purulent sputum, consolidation on CXR, or clinical signs of pneumonia. •Theophylline —if not responding to nebulized bronchodilators. •Non-invasive ventilation for persistent hypercapnic ventilatory failure oAsk the COPD CNS to triage and commence NIV if appropriate |
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