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CDHB

Management of COPD

General Principles

• Inhaled bronchodilators are effective treatments for acute exacerbations.
• Nebulized treatment is simpler to administer, but does carry a risk of spread of droplet infections such as influenza. An aerosol inhaler should be used with a spacer device in the acute setting if possible. If nebulizer therapy is used, this should be changed to inhalers at the earliest convenient time.
• Systemic glucocorticoids reduce the severity of and shorten recovery from acute exacerbations.
• Non-invasive positive pressure ventilation is effective for acute hypercapnic ventilatory failure. This requires admission to the Non-Invasive Ventilation (NIV) unit on Ward 25 or the ICU.
• Exacerbations with clinical signs of infection (increased volume and change in colour of sputum and/or fever, leukocytosis) benefit from antibiotic therapy. Oral therapy is usually sufficient unless there is evidence of pneumonia.
• Controlled oxygen delivery (24-28% by Venturi mask) or 0.5 - 2 L/min by nasal prongs, aiming for sat.O₂ of 88-92% is indicated for significant hypoxaemia. Prescribe oxygen therapy, including device, flow rate, and target sat.O₂.
• Assess and document smoking status. If the patient is heavily nicotine addicted, suggest the use of nicotine replacement therapy - regardless of the patient's intention or readiness to quit smoking. See the section on Nicotine Dependent Patients.

Emergency Treatment of COPD

• If respiratory arrest, unconscious patient, upper airway compromise, call ICU immediately.
• Prepare for emergency intubation and assisted ventilation.
• Consider tension pneumothorax.
• Notify Respiratory Physician or General Physician on call.
• Initiate action for severe exacerbation (see below).

Management of Severe Exacerbation of COPD

• Immediately obtain an arterial blood gas (ABG).
• Commence controlled oxygen therapy (24-28% by Venturi mask) or 0.5 - 2 L/min by nasal prongs to maintain a PaO₂ >60 mm Hg or sat.O₂ 88-92%. For more information, see Oxygen Therapy. Monitor for rising PaCO₂ (hypercapnia).
• Nebulized salbutamol 5 mg and ipratropium 0.5 mg stat and 2-6 hourly according to clinical response. Nebulize using compressed air if PaCO₂ elevated or there is concern the patient may be retaining CO₂.
• Give oral prednisone 40 mg (IV hydrocortisone 200 mg if unable to take orally).
• Review ABG:
  • If pH <7.35 and PaCO₂ >45 mm Hg, all patients should be considered for ventilatory support and must be discussed with the Respiratory Physician on call. See Non-Invasive Ventilation.
• Consider IV antibiotics for the first one or two doses then change to oral therapy if the patient has two out of three of the following: purulent sputum, increased sputum production, increasing dyspnoea.

  

  • amoxicillin/ clavulanate 1 g/200 mg iv eight hourly then 500 mg/125 mg po three times a day
• If consolidation on CXR, treat as community-acquired pneumonia.
• If concern about sputum retention, consider chest physiotherapy.
• There is no evidence of benefit for intravenous bronchodilators, either IV salbutamol or aminophylline, over inhaled treatments. There is evidence of greater adverse events with IV aminophylline, but if you believe IV aminophylline may be indicated, discuss with a Respiratory Physician. Guidelines for aminophylline dosage are available - search for "theophylline" on the CDHB intranet. If inhaled treatments do not improve the situation consider ICU, Non-Invasive Ventilation. Always discuss ceiling of care.

Non-Invasive Ventilation (NIV)

All patients should be assessed for the need for NIV through the use of Bilevel Positive Airway Pressure (BiPAP) ventilation using a face mask. NIV has been shown to be an effective treatment for acute hypercapnic respiratory failure, particularly in COPD. In this patient group, NIV has been shown to reduce mortality, hospital stay and costs.

Patients will be eligible for NIV in the Ward 25 NIV Unit if they fulfil the following entry criteria:

• The patient must have a clearly established diagnosis of COPD, and be acidotic (pH <7.35) and hypercapnic (PaCO₂ >45 mm Hg) on arterial blood gas analysis.
• If the patient's pH is <7.25 then NIV should be delivered in ICU, unless the patient has been assessed by the medical team as not for endotracheal intubation or ICU referral. If this is the case, referral to Ward 25 NIV unit should still be considered.
• Every patient fulfilling the above criteria must be discussed with and agreed to by the acute Respiratory Physician before NIV is started. Thereafter the care of the patient will continue under Respiratory Services.
• Before NIV is commenced, a ceiling of care must be established. A decision must be made whether the patient is for endotracheal intubation and transfer to ICU if NIV fails. This decision must be clearly documented in the patient's clinical notes along with their resuscitation status.
• If the patient is for endotracheal intubation in the event of clinical deterioration, then the admitting Registrar must notify the ICU team that the patient is being admitted to the Ward 25 NIV unit.
• All patients admitted for NIV on Ward 25 must be reviewed by an Acute On-call Registrar within 30 mins of being notified of the ABG result obtained after 1 hour of NIV treatment, or sooner if requested by nursing staff. Their status is to be reported to the acute Respiratory Physician.

Patients other than those with hypercapnic respiratory failure secondary to COPD may be considered for NIV at the discretion of the acute Respiratory Physician and in consultation with the ward 25 nurse in charge.

• NIV nurse - 89250.

Exclusion Criteria: NIV is generally excluded if the patient has any of the following:

Treatment of Mild or Moderate Exacerbation of COPD

• Oxygen (see Oxygen Therapy).
• Inhaled salbutamol or salbutamol/ipratropium, via a spacer device. Note that nebulizer treatment may potentially spread droplet infection.
• Oral prednisone 40 mg stat; then 40 mg mane until clinical response adequate; then 20 mg mane for an equal number of days; then stop or reduce to usual maintenance dose. There is no evidence of benefit for oral steroids beyond 14 days. Regular oral steroid treatment has not been shown to alter outcomes, and is associated with a poor side effect profile, including muscle weakness and osteoporosis.
• Oral antibiotics (IV if unable to take orally) are appropriate if there is evidence of two out of three of the following: purulent sputum, increased sputum production, increasing dyspnoea.
  • Use single agent oral antibiotic e.g., amoxicillin 500 mg PO three times a day, or doxycycline 200 mg PO day 1 then 100 mg PO once a day.
  • If IV therapy is necessary use amoxicillin 1 g q8h.
• If consolidation on CXR, treat as community-acquired pneumonia.
• Consider chest physiotherapy.
• Anxiety reduction strategies and breathing control exercises are important, since anxiety often complicates admission with COPD.
• Aim for early mobilization, to avoid further deconditioning.

Monitor Progress

• Oxygen therapy:
  • Monitor sat.O₂ and aim to maintain 88-92%.
  • Monitor for hypercapnia (symptoms of drowsiness and/or confusion). If there is a risk of hypercapnia this should be documented and oxygen should be prescribed to achieve a target sat.O₂ of 88-92%.
  • Perform ABG if evidence of falling sat.O₂ or clinical deterioration.
• Clinical monitoring:
  • Check for fatigue - beware respiratory paradox.
  • Pulse rate.
  • Sputum volume and appearance.
  • Peak Expiratory Flow Rate (PEFR).
• Adjustment of treatment: individual patient needs may change during the course of treatment including the frequency and dose of bronchodilator, fluid and electrolyte requirements and bronchial secretions (chest physiotherapy for retained bronchial secretions). Commence oral therapy as soon as condition stabilizes. Bronchodilators should be given by Metered Dose Inhaler (MDI) and spacer.

Discharge Planning/Rehabilitation

• Involving the patient's GP in a case conference and developing a care plan may facilitate early discharge. Discharge planning should start on admission and be documented within 24-48 hours. It may be useful to identify external factors such as health-care utilization behaviours that are amenable to change, to reduce likelihood of readmission (absence of self-management skills, involvement of Emergency Department or ambulance services without considering primary care / community options, high patient or carer anxiety).
• It is helpful to obtain spirometry and ABG at discharge.
• Assess for comorbidities.
• Most patients will benefit from enrolment into an out-patient rehabilitation programme, including COPD education and a self-management plan. Rehabilitation programmes are now available around Christchurch. Details, including the referral process, can be found on HealthPathways.
• Arrange smoking cessation advice for current smokers (each ward has nurses trained in smoking cessation - ask the Charge Nurse for details). Facilitate a referral to a cessation programme such as the PEGS (Preparation, Education, Giving Up and Staying Smokefree) programme, or Quitline. Consider prescribing nicotine replacement therapy via a Quitcard prescription. See Nicotine Withdrawal.
• Consider nutritional supplement (requires a PHARMAC Special Authority application) and advice for underweight patients.
• Advise influenza vaccination each autumn.
• Encourage regular exercise.
• Suggested criteria for a patient's readiness for discharge include:
  • The patient should be in a clinically stable condition and have had no parenteral therapy for 24 hours.
  • Inhaled bronchodilators are required less than four-hourly.
  • Oxygen no longer required (unless home oxygen is indicated - see Domiciliary Oxygen).
  • If previously able, the patient is ambulating safely and independently, and performing activities of daily living.
  • The patient is able to eat and sleep without significant episodes of dyspnoea.
  • The patient or caregiver understands and is able to administer medications.
  • Follow-up and home care arrangements (e.g., CREST (Community Rehabilitation Enablement Support Team), home oxygen, home-care, Meals on Wheels, community nurse, allied health, GP, Specialist) have been completed.

    Note: Pathways for the integrated management of a number of chronic medical conditions, including COPD and other respiratory diseases, have been developed as part of the Canterbury Initiative. These pathways can be accessed via HealthPathways.

References:

The COPDX Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2009. http://www.copdx.org.au/

NICE UK guideline on management of COPD in adults. CG101 June 2010.

GOLD: Global Initiative for the diagnosis, management, and prevention of COPD 2008. http://www.goldcopd.org/

Topic Code: 1635