COPD acute exacerbation plan
Initial assessment of severity
Assessment of severity of the exacerbation includes a medical history, examination, spirometry and blood gas measurements, chest x-rays and electrocardiography.
- Arterial blood gases:
- Chest x-ray and electrocardiogram:
An acute exacerbation of COPD may involve an increase in airflow limitation, excess sputum production, airway inflammation, infection, hypoxia, hypercarbia and acidosis. Treatment is directed at each of these problems.
Inhaled beta-agonist (eg, salbutamol, 400–800 mcg; terbutaline, 500–100 mcg) and anticholinergic agent (ipratropium, 80 mcg) can be given by pressurised metered dose inhaler and spacer, or by jet nebulisation (salbutamol, 2.5–5 mg; terbutaline, 5 mg; ipratropium, 500 mcg). The dose interval is titrated to the response and can range from hourly to six-hourly.
Oral steroids hasten resolution and reduce the likelihood of relapse. Up to two weeks’ therapy with prednisolone (40–50 mg daily) is adequate. Longer courses add no further benefit and have a higher risk of side effects.
Antibiotics are given for purulent sputum to cover for typical and atypical organisms.
- Controlled oxygen therapy:
This is indicated in patients with hypoxia, with the aim of improving oxygen saturation to over 90% (PaO2 > 50 mmHg, or 6.7 kPa). Use nasal prongs at 0.5–2.0 L/minute or a venturi mask at 24% or 28%. Minimise excessive oxygen administration, which can worsen hypercapnia.
- Ventilatory assistance:
This is indicated for increasing hypercapnia and acidosis. Non-invasive positive pressure ventilation by means of a mask is the preferred method.