Management

Treatment options for COPD include the following:

Bronchodilators and oxygen therapy

• Increased dose of short acting bronchodilators which can be inhalers or nebulisers as indicated [4]
• The most commonly used bronchodilators in the ED are Beta 2 agonists such as salbutamol and terbutaline, and anticholinergics such as ipratropium bromide
• Bronchodilators improve FEV and symptoms; there is thought to be no difference between the classes of short acting bronchodilators [9]
• The recommendation is to increase the dose and frequency of a patient’s existing medication regime [9]
• If a patient is acidotic or hypercapnic, nebulisers should be driven by air not oxygen [4]
• Oxygen should be given to maintain saturations in a targeted range which should normally be 88-92% [4]

Steroids

• Oral corticosteroids should be used in all patients admitted to hospital or in the community if their breathlessness interferes with their activities of daily living, unless there is a significant contraindication [4]
• Steroids improve symptoms, FEV and PaO₂ in moderate to severe exacerbation [9]
• Steroid use reduces treatment failure, relapse and length of hospital stay [9]
• Prednisolone 30 mg should be given for 7 to 14 days [4]
• There is no advantage in a course of steroids with duration beyond 14 days [4]

Learning bite

Corticosteroids should be given to all those admitted with an exacerbation of COPD and to those being treated at home where their symptoms are affecting their activity of daily living.

Antibiotics

• Antibiotics should be given to patients with an increase in purulent sputum, consolidation on CXR or clinical signs of pneumonia [4]
• Empirical antibiotic therapy should be with aminopenicillin, macrolide or tetracycline unless local microbiological policy states otherwise [4]

Learning bite

Antibiotics should be given to those with purulent sputum or those with clinical signs of pneumonia or CXR changes.

Theophylline / aminophylline

• Intravenous aminophylline should be considered only if there is an inadequate response to nebulised bronchodilators [4]. The loading dose of aminophylline should be omitted in patients taking oral theophylline
• The dose of oral theophylline should be reduced at the time of an exacerbation if the patient needs concurrent macrolide or fluroquinolone antibiotics

Non-invasive ventilation

NIV is the preferred initial mode of ventilation to treat acute respiratory failure for patients with an acute exacerbation of COPD. NIV improves oxygenation and acidosis, decreases respiratory rate, work of breathing and severity of breathlessness.

The British Thoracic Guidelines 2008 state that NIV should be considered within 60 minutes of hospital arrival in all patients with an acute exacerbation of COPD in whom a respiratory acidosis persists despite maximum medical treatment.

Maximum medical treatment includes:

• Controlled oxygen therapy to maintain SaO2 88-92%
• Nebulised salbutamol 2.5-5 mg
• Nebulised Ipratropium 500 micrograms
• Prednisolone 30 mg
• Antibiotic agent (when indicated)

GOLD strategy 2018 Indications for NIV include:

• pH <7.35 and a PaCO2 >6kPa or 45mmHg
• Severe dyspnea with clinical signs suggestive of muscle fatigue, increases work of breathing, such as use of respiratory muscles, paradoxical motion of the abdomen, or retraction of the intercostal spaces.
• Persistent hypoxaemia, despite supplemental oxygen therapy

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Those patients who are hypercapnic despite optimal medical therapy should be considered for NIV.

Inclusion criteria for NIV:

• Primary diagnosis of COPD exacerbation
• Able to protect airway
• Conscious and cooperative
• Patient’s wishes considered and potential quality of life acceptable for patient

* NIV can be considered in the unconscious if within a critical care setting or intubation is inappropriate

Exclusion criteria for NIV:

• Life threatening hypoxaemia
• Severe co-morbidity
• Confusion/agitation/cognitive impairment
• Facial burns/trauma/recent facial or upper airway surgery
• Vomiting
• Fixed upper airway obstruction
• Undrained pneumothorax
• Upper gastrointestinal surgery
• Inability to protect the airway
• Copious respiratory secretions
• Haemodynamically unstable requiring inotropes/vasopressors (unless in critical care unit)
• Patient moribund
• Bowel obstruction
• Patient declines treatment

Commencing NIV:

• The decision to commence NIV should be made by a doctor of ST2 level or above who is trained and competent to use NIV.
• Before commencing NIV there should be a clear plan of escalation and ceilings of treatment [4]. This should be documented in the patient notes
• The patient should be sat in a semi-recumbent position, and a full facemask used for the first 24 hours, switching to a nasal mask if preferred by patient.
• An initial Inspiratory Positive Airway Pressure (IPAP) of 10 cm H20 and Expiratory Positive Airway Pressure (EPAP) of 4-5 cm of water should be used. This should be increased rapidly at a rate of approximately 5 cm of water every 10 minutes to a target of 20 cm H2O (IPAP), or patient unable to tolerate further, or therapeutic response achieved [10].
• If a patient benefits from NIV in the first 4 hours, they should be continued on NIV for as long as possible

Monitoring NIV:

• Arterial blood gas (ABG) analysis should be performed at baseline, 1 hour after commencing NIV, 4 hours after commencing NIV, and 1 hour after changing any settings
• All patients should be on continuous pulse oximetry and ECG monitoring for the first 12 hours [10].

Indications for invasive mechanical ventilation:

• A decision to intubate and proceed with mechanical ventilation should normally be made within 4 hours of starting NIV, as improvements should usually be apparent during this time [10]
• Patients with COPD should be considered for ITU treatment when necessary [4], especially if they are more unwell i.e. pH < 7.26 [10]

Invasive Mechanical Ventilation

Indications (as per Global Initiative for Chronic Obstructive Lung Disease 2018):

• Inability to tolerate NIV or NIV failure
• Status post respiratory or cardiac arrest
• Diminished consciousness, psychomotor agitation inadequately controlled by sedation
• Massive aspiration or persistent vomiting
• Persistent inability to remove respiratory secretions
• Severe ventricular or supraventricular arrhythmias
• Severe haemodynamic instability unresponsive to fluid and vasopressors
• Life threatening hypoxaemia in patients unable to tolerate NIV

Other therapy

• Hospital at home and assisted discharge schemes are safe, effective and should be considered in patients who would otherwise require hospital admission [4]
• Patients should be advised and assisted with smoking cessation [4]