1. Managing acute exacerbations of COPD in primary care.
Clinical Knowledge Summaries CKS Chronic obstructive pulmonary disease (COPD)
Managing acute exacerbations of COPD in primary care.
Educational slides based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

2. Key learning points and objectives
To be able to:
Recognise people who are having an acute exacerbation of COPD.
Assess which patients should be admitted to hospital.
Describe how to manage patients who do not require hospital admission.
Describe when to prescribe an antibiotic and which antibiotic should be chosen.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

3. Self management plan
People who have frequent exacerbations, should be provided with a structured, written action plan on:
How to recognize when COPD is getting worse (increased breathlessness, more sputum, coloured sputum, and/or fever).
How to initially increase the use of short-acting bronchodilators, and if there is no response, when to contact a primary healthcare professional.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

4. Self management plan
If a person has a supply of medication at home, provide written information advising them:
To start oral corticosteroid therapy if their increased breathlessness interferes with activities of daily living.
To start antibiotics if sputum becomes discoloured or increases in volume.
To contact a primary healthcare professional if they start treatment or are uncertain about whether to start treatment.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

5. Diagnosing an acute exacerbation
An acute exacerbation of COPD is:
A sustained worsening of symptoms from the 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.
Common symptoms include:
Increased breathlessness.
Increased cough.
Increased sputum production and change in sputum colour.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

6. Diagnosing an acute exacerbation
Other symptoms may include:
Increased wheeze and chest tightness.
Upper respiratory tract symptoms (for example cold or sore throat).
Reduced exercise tolerance.
Fluid retention.
Increased fatigue.
Acute confusion.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

7. What else might it be?
Conditions which present with symptoms similar to those of an acute exacerbation of COPD include:
Pneumonia.
Pneumothorax.
Left ventricular failure/pulmonary oedema.
Pulmonary embolism.
Lung cancer.
Upper airway obstruction.
Pleural effusion.
Recurrent aspiration.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

8. Assessing an acute exacerbation
The following physical signs are features of a severe exacerbation:
Marked dyspnoea and tachypnoea, pursed-lip breathing, use of accessory muscles at rest.
Beyond normal day-to-day variations.
Acute confusion.
New-onset cyanosis or peripheral oedema.
Marked reduction in activities of daily living.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

9. Assessing an acute exacerbation
Assess oxygen saturation using pulse oximetry.
Do not send sputum samples for culture routinely.
Consider the need for hospital admission.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

10. When to admit? Consider admission if:
Severe breathlessness, confusion, cyanosis, worsening peripheral oedema, or impaired consciousness are present.
Unable to cope or lives alone.
The general condition is poor or deteriorating (e.g. poor activity, confined to bed, or on long-term oxygen therapy).
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

11. When to admit? Consider admission if:
Significant comorbidity (particularly cardiac disease or type 1 diabetes mellitus).
A low oxygen saturation (less than 90% - pulse oximetry).
New acute changes on chest X-ray (if requested and available locally and urgently).
X-ray is mainly requested to exclude alternative or concomitant diagnoses, for example pneumonia.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

12. Hospital at home schemes
Hospital at home schemes may be available in some areas and are an alternative to hospital admission.
Difficult to make firm recommendations as to which patients are most suitable for these schemes.
May be suitable for people with few of the indications for hospital admission who prefer treatment at home.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

13. While awaiting transfer to hospital
Check oxygen saturation on air in people with a severe acute exacerbation and give oxygen if less than 90%. 
Follow instructions on an oxygen alert card, if available.
If the person does not have an oxygen alert card (indicating risk of hypercapnia):
Use a 28% Venturi mask at a flow rate of 4 L/min, and
Aim for an oxygen saturation of 88–92%.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

14. Management while waiting admission
If the oxygen saturation remains below 88% despite a 28% Venturi mask:
Change to nasal cannulae at 2–6 L/min or a simple mask at 5 L/min with target saturation of 88–92%.
In this situation, request an emergency ambulance and alert A&E or medical admissions unit that the patient requires immediate senior assessment on arrival.
If the oxygen saturation decreases after commencing oxygen:
Change to a 24% Venturi mask at a flow rate of 2 L/min.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

15. Managing if not admitted
Advise the person to:
Take increased doses or increase the frequency of use of short-acting bronchodilators (e.g. double the dose).
Keep to the same delivery system (e.g. inhaler with spacer or nebulizer).
Use a spacer if not already using one.
Easier to use and delivers maximum dose.
If the person is likely to become fatigued, a nebulizer may be more appropriate.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

16. Managing if not admitted
Prescribe systemic corticosteroids for people with a significant increase in breathlessness that interferes with daily activities.
Prescribe prednisolone 30 mg orally once daily for 7–14 days.
Consider osteoporosis prophylaxis for people requiring frequent courses of oral corticosteroids. 
Presenter notes
An RCT reviewed here, found that a 5-day course of systemic corticosteroids is not inferior to 14-day treatment in people presenting to hospital with acute exacerbation of COPD.
 From ‘Eyes on the Evidence Issue 56 – December ‘
Expert commentary from Professor PMA Calverley, Professor of Respiratory Medicine, University of Liverpool:
"Although oral corticosteroids accelerate recovery from a COPD exacerbation and
reduce the risk of relapse, how long treatment should last is less clear. As recommended by the NICE
guidance, giving high dose corticosteroids for more than 14 days has no advantage. Now this large
Swiss study has found no difference between 5 and 14 days of treatment. However, the total dose of
corticosteroids given over the first 5 days in this study was similar to the doses in lower end of the 7 to
14 day course recommended by NICE. In addition, all patients received a 7-day course of antibiotics, a
nebulised short-acting bronchodilator as needed, regular tiotropium, and inhaled combination
glucocorticoid and long-acting beta-2 agonist. As a result, some patients may have been treated more
intensively than recommended by NICE guidance.
"The important message from this study is that less oral corticosteroid therapy may be needed to treat
exacerbations in patients on intensive inhaled treatment with long-acting bronchodilators and inhaled
corticosteroids. The new data relate to patients with severe disease, but this is typical of studies of
systemic corticosteroids for COPD exacerbations. It seems unlikely that less severe disease would
need a longer course of treatment than is needed in sicker patients." –
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

17. Managing if not admitted
Prescribe oral antibiotics for people with a history of increasingly purulent sputum or clinical signs of pneumonia. 
Empirical treatment should usually be:
Amoxicillin 500 mg three times daily for 5 days, or
A tetracycline (e.g. doxycycline 200 mg on the first day then 100 mg once daily, for a total of 5 days), or
A macrolide, if allergic to amoxicillin and tetracycline (e.g. clarithromycin 500 mg twice daily for 5 days).
Prescribe co-amoxiclav 625 mg three times daily for 5 days if the person has antibiotic resistance risk factors such as:
Comorbid disease,
Severe COPD,
Frequent exacerbations, or
Antibiotic use in the past 3 months.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

18. Follow up During an acute episode:
The frequency of follow up will be dictated by clinical judgement and severity of illness.
Follow up once the person is clinically stable (e.g. 6 weeks after the onset of symptoms of the exacerbation):
Manage any residual or changed symptoms.
Optimize medical treatment to reduce the risk of further exacerbations.
Consider referral or re-referral to pulmonary rehabilitation.
Review the self-management plan.
Check for any problems arising with medications.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).

19. Summary Consider hospital admission if:
Severe breathlessness, confusion, cyanosis, worsening peripheral oedema, or impaired consciousness.
Unable to cope or lives alone.
General condition is poor or deteriorating (poor activity, confined to bed, or on long-term oxygen therapy).
Significant comorbidity (particularly cardiac disease or type 1 diabetes mellitus).
A low oxygen saturation (less than 90%).
If managing the patient’s exacerbation in the community:
Increase the dose or frequency of short acting bronchodilators.
Advise the use of a spacer or nebuliser.
Consider oral corticosteroids.
Consider empirical antibiotics if there is a history of more purulent sputum or clinical signs of pneumonia.
Based on the CKS topic Chronic obstructive pulmonary disease (November 2010), and NICE guidance; Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (2010).