Acute exacerbations of COPD
By looking at 3 case histories, this module offers insights into the causes and management of acute exacerbations of COPD, differential diagnosis and post-exacerbation follow-up.
- Be aware of the incidence of COPD exacerbations
- Recognise the causes of COPD exacerbations
- Diagnose and manage an acute COPD exacerbation
- Be familiar with the differential diagnoses of an acute exacerbation of COPD
- Master the follow-up post discharge
This module was created by Dr. Kevin Gruffydd-Jones, a GP from Wiltshire, Joint Policy Lead for the Primary Care Respiratory Society UK and member of the National COPD Audit Primary Care Committee.
Chronic obstructive pulmonary disease (COPD) caused 29,776 deaths in the United Kingdom in 2012, according to the British Lung Foundation.1 Acute exacerbations of chronic lung disease accounted for 190,000 hospital admissions in England in 2014-2015, the second-highest cause of hospital admission in that period.2
The Global Initiative for Lung Disease (GOLD) defines an exacerbation of COPD as:
‘…an acute event characterised by a worsening of the patient’s respiratory symptoms that is beyond day-to-day variation and leads to a change in medication.’3
The multinational ECLIPSE study of 2138 patients published in 2010 showed that the exacerbation rate of patients with COPD varied from an average of 0.85 events per year in patients with moderate airflow limitation to 2.0 events per year in patients with severe airflow limitation.4
The most common cause of exacerbations of COPD is acute respiratory tract infection, both viral and bacterial.
Bacteria can be found in just over 50% of bronchoscopic brushings taken during an acute exacerbation and this percentage increases in line with the severity of attack. However, many of these bacteria will also be found in the stable state and therefore it is difficult to say how many of these are pathogenic (i.e. actually cause the infection).
The most commonly found bacteria are Streptococcus pneumoniae, Haemophilus influenzae and Moxharella catarrhalis. With an increased severity of attack Pseudomonas aeruginosa is increasingly found. Rhinovirus infection is the most common viral infection.
Other linked factors are:
- Atmospheric pollution
- Cold weather
- ‘Unknown’ in about one third of cases
Bert is a 75-year-old retired fitter who lives by himself. He was diagnosed as having COPD 10 years ago. He also suffers from osteoarthritis of the knees, for which he takes paracetamol when needed. He usually has mild breathlessness on exertion and takes salbutamol as relief medication administered via metered-dose inhaler (MDI) and tiotropium given regularly once per day via a dry-powder inhaler (DPI). Over the last two days he has rapidly become short of breath on dressing, and he is using his salbutamol every 4 hours. He has also started coughing up green sputum.
Presentation of an acute exacerbation
Symptoms can range from a mild worsening of everyday symptoms (increased sputum production, purulence of cough, dyspnoea, chest tightness) in a mild attack, to acute respiratory distress with confusion, exhaustion and an increase in right-sided heart failure (cor pulmonale) with peripheral oedema in a severe attack.
History and examination
The history and examination are directed towards assessing:
- If there is an alternative diagnosis to account for the symptoms
- Past history of attacks (e.g. needing hospital admission/mechanical ventilation)
- Presence of any significant co-morbidities (e.g. diabetes)
- Social circumstances including available care
- Treatment of the current attack to date
- The severity of the attack
On examination, Bert is apyrexial, with a pulse rate of 120/min, mild intercostal recession and with bilateral wheezes and crackles in his chest
Which of the following should be used in the assessment of the acute attack in primary care?
According to NICE the following signs are features of a severe exacerbation:5
- Marked dyspnoea and tachypnoea (respiratory rate >25/min)
- Purse lip breathing
- Use of accessory muscles (sternomastoid and abdominal) at rest
- Acute confusion
- New-onset cyanosis
- New-onset peripheral oedema
- Marked reduction in activities of daily living
There may be only minor changes in lung function in an acute attack so measurement of FEV1 and peak flow is not recommended. Sputum analysis is of little value in the initial assessment but may be useful to identify pathogens such as Pseudomonas if initial antibiotic therapy is unsuccessful.
Pulse oximetry measurements are essential and guide the need for oxygen therapy and/or hospital admission (see below).
Bert’s respiratory rate is 25/min and oxygen saturations in air are 86%.
Management of the acute attack in primary care
There is a paucity of clinical trials looking at the effectiveness of short-acting beta-2 agonists in acute attacks of COPD. Both NICE and GOLD guidelines recommend the use of short-acting bronchodilator therapy and cite evidence that there is no difference in outcomes if therapy is delivered via an MDI and spacer device or via nebuliser.3,5
In general, in primary care a suitable regime would be salbutamol 4 x 100mcg doses administered every 3-4 hours via a large volume spacer device, unless the patient had difficulty using an MDI-spacer in which case salbutamol 5mg should be given via an air-driven nebuliser.
Measurement of blood oxygen saturations using pulse oximetry is vital to guide oxygen therapy in primary care. Oxygen should be given if the patient is hypoxic (if oxygen saturations are less than 88% in air).6
Some patients with chronic COPD rely on a slightly low blood oxygen level to drive respiration. If high flow oxygen is used to correct hypoxaemia in these patients, this raises the blood oxygen level too high: the drive to respiration is lost, and the patient can develop hypercapnic (high blood carbon dioxide) respiratory failure.
It is therefore very important that oxygen is delivered at a relatively low flow rate of 2-4l/min, ideally via a rate-limiting device such as a Venturi mask.
There is strong evidence that oral steroids can improve lung function, reduce hypoxaemia, hasten recovery and reduce the rate of relapse when administered during an acute exacerbation. NICE guideline CG101 recommends a 7-14 day (maximum) course of 30mg oral prednisolone for patients with acute breathlessness sufficient to alter daily activities from baseline.5 There is no need to tail off the dose unless the patient is on maintenance oral steroid therapy for more than 3 weeks.
Evidence from patients with moderate to severe exacerbations shows that the administration of antibiotics can shorten the duration of attacks and reduce mortality.7
The use of a 5-10 day course of antibiotics is recommended for patients where there is an increase in sputum purulence plus an increase in sputum volume and/or dyspnoea.5
Amoxycillin 500mg three times daily is the first choice, but clarithromycin or doxycycline may be suitable alternatives. Sputum culture is not routinely indicated, but if there is failure to respond to first-line therapy, then sputum culture may identify the presence of Pseudomonas (common in patients with co-existent bronchiectasis) in which case treatment with a quinolone antibiotic may be more appropriate.
Patients not admitted to hospital should receive written instructions about when to seek help. The timing of follow-up depends on the severity of the social circumstances but should be at least at 7 days, to review the need for further antibiotic treatment and/or oral steroid therapy.
Bert was given low flow rate oxygen via a Venturi mask. He was given 6x100mcg salbutamol via a metered dose inhaler and started on 30mg oral steroids. His general situation improved after 15 minutes; he had a respiratory rate of 20/min and oxygen saturation of 92% on oxygen.
Table 1: Factors that should be used to assess the need to treat patients in hospital5
As Bert lives alone and initially presented with oxygen saturations of 86%, he was admitted to hospital and was discharged 4 days later.
Jean is a 45-year-old travel journalist, who was diagnosed as having COPD associated with alpha-one-antitrypsin deficiency 5 years ago. She uses salbutamol as necessary, but over the last 3 weeks has had recurrent attack of breathlessness which have only been partially relieved by her salbutamol. She has an associated dry cough. There is no history of prior respiratory tract infection. She has no other medical problems.
On examination she is apyrexial, respiratory rate 20/min, pulse rate 110/min, and her regular oxygen saturations in air are 94%. Cardiovascular and chest examination is otherwise normal.
The differential diagnoses of an acute exacerbation of COPD are shown in Table 2.
There are no real signs of pneumonia or acute heart failure. There are no signs of a pneumothorax; however, as small pneumothorax can be difficult to detect clinically, arranging a chest x-ray is important when the diagnosis is in doubt.
Jean’s job as a travel journalist may be associated with foreign travel and raises the possibility of a diagnosis of pulmonary embolism.
An urgent D-dimer test was arranged and levels were found to be markedly raised. She was referred to the urgent assessment unit of the local hospital where a CTPA (computerised tomography pulmonary angiogram) showed the presence of multiple pulmonary emboli, probably arising from a business trip to South Africa undertaken three weeks earlier.
Table 2: Differential Diagnoses of COPD exacerbation5
• Left ventricular failure/pulmonary oedema
• Pulmonary embolus
• Upper airway obstruction
• Pleural effusion
• Recurrent aspiration
Joan is a 78-year-old woman who has just been discharged from hospital after an acute exacerbation of COPD. She is on salbutamol via MDI and salmeterol/fluticasone via dry powder inhaler. You review her in the surgery, one week post-discharge from hospital.
There is a high rate of morbidity following an acute exacerbation of COPD. 15% of patients will die and 30-40% patients will be readmitted after hospitalisation for acute COPD. Review of patients in primary care is essential to minimise these risks, and NICE COPD Quality Standard QS10 (2011) recommends that patients hospitalised with an acute exacerbation of COPD are reviewed within 2 weeks of discharge.8 Table 3 highlights the factors that should be dealt with at the initial follow-up visit.
Table 3: Factors to consider at initial follow-up following hospitalization for COPD
Is there sufficient support for patient and carer? (e.g. social, occupational therapy)
Is there any evidence of depression/anxiety?
Is the patient’s medical state stable?
Review need for alteration of treatment e.g antibiotics/ steroids
Is there a need for supplemental oxygen?
Check inhaler technique
Has the patient been referred?
Are there any significant co-morbidities that need attention e.g heart failure?
Early (within 4 weeks of discharge) pulmonary rehabilitation has been shown to reduce hospital readmission but its provision in many areas is very variable. The need for referral for assessment for long-term oxygen therapy using pulse oximetry should be delayed until the patient is stable i.e. 6 weeks post-exacerbation.
A further review is recommended after 4-6 weeks post-exacerbation, in the community or after hospital discharge.
The aims of the consultation are:
- To check that the patient is medically stable
- To prevent future exacerbations
Table 4 shows points to cover at this stage.
Table 4: Review 4-6 weeks post-exacerbation
|Is the patient medically stable?
Has the patient returned to their usual activities of daily living and degree of breathlessness?
Check pulse oximetry: if oxygen saturations in air are <92% consider referral for oxygen assessment
Assess co-morbidities: e.g. if frequent exacerbations consider osteoporosis, consider depression
Assess social needs: have the patient and carer got appropriate support?
Prevention of future exacerbations:
What were the circumstances of the exacerbation? Are there any preventable trigger factors?
Review of pharmacological therapy including inhaler technique and concordance
Review of non-pharmacological therapy e.g. smoking status, weight management, pulmonary rehabilitation, influenza and pneumococcal immunization status
Self-management education including action plans
Check for high risk indicators and consider including the patient on the high risk register or Gold Standard Framework/Palliative Register as appropriate
Multicomponent assessment and prognostic tools such as DOSE and BODE score can help identify patients with advanced disease
More detailed advice given in the prevention of exacerbations and an example of a self-management plan are given in the PCRS-UK publication Diagnosis and management of COPD in primary care.9
Ideas for audit:
- Episodes of acute exacerbations where there is a record of respiratory rate and/or oxygen saturations.
- Number of patients discharged from hospital with an acute exacerbation of COPD reviewed within 2 weeks of discharge.
- Number of patients hospitalised for an acute exacerbation referred for pulmonary rehabilitation within 4 weeks of discharge
- British Lung Foundation. Chronic obstructive pulmonary disease (COPD) statistics. 2016. Available at: statistics.blf.org.uk/copd. Last accessed: 10th August 2016.
- Available at: digital.nhs.uk/hesdata
- Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, 2016. Available at: goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Last accessed:
- Hurst JR, Vestbo J, Anzueto A, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med 2010; 363: 1128-38.
- NICE Guideline CG101. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. 2010. Available at: www.nice.org.uk/guidance/cg101. Last accessed: 09th August 2016.
- British Thoracic Society Emergency Oxygen Use in Adult Patients Guideline 2015 (draft). Available at: brit-thoracic.org.uk/guidelines-and-quality-standards/emergency-oxygen-use-in-adult-patients-guideline/. Last accessed:
- Vollenweider DJ, Jarrett H, Steurer-Stey CA, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease (Review). Cochrane Database Syst Rev 2012; 12. CD010257.
- NICE Quality Standard QS10. Chronic obstructive pulmonary disease in adults. 2011. Available at: nice.org.uk/guidance/QS10. Last accessed: 09th August 2016.
- Diagnosis and management of COPD in primary care 2015. Available at: www.pcrs-uk.org/resource/Guidelines-and-guidance/QGCOPD. Last accessed:
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