managing exacerbations of copd...paper copies of this document if you are reading a printed copy of...
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Managing Exacerbations of COPD (Version 3.0)
Ratified Date: 12/10/2015 Launch Date: 13/10/2015 Review Date: 13/10/2018 Guideline Author: Alice Turner
Guideline Objectives The aim of this guideline is to ensure that robust diagnoses of exacerbation of COPD are made, and that patients are managed according to national standards. This may help to reduce in-patient mortality. If care bundles are used effectively we may also help to reduce readmissions and longer term mortality
Guideline Readership This guideline is intended for use in patients with a confirmed diagnosis of a chronic obstructive pulmonary disease (COPD) exacerbation. Please see the COPD diagnosis guideline if you are unsure regarding the diagnosis of COPD. An exacerbation is a sustained worsening of the patient’s usual symptoms that requires additional treatment. If there is a change in sputum volume or colour alongside breathlessness then this may be an infective exacerbation. If there is no sputum, and no signs of infection clinically it may be non-infective. The main difference between the two types of exacerbation is that antibiotics are not required if it is non-infective. This guideline is intended for all staff involved in the management of these episodes in hospital.
Other Guidance NICE guideline BTS guideline National COPD quality standards There are no major differences from these
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1. Flow Chart *There is only a respiratory take at the BHH site. At GHH and Solihull please alert the respiratory CNS that the patient has been admitted instead. Please see the respiratory web page for further information. 2. Executive Summary & Overview This guideline is intended for use in patients with a confirmed diagnosis of a chronic obstructive pulmonary disease (COPD) exacerbation. Please see the COPD diagnosis guideline if you are unsure regarding the diagnosis of COPD. An exacerbation is a sustained worsening of the patient’s usual symptoms that requires additional treatment. If there is a change in sputum volume or colour alongside breathlessness then this may be an infective exacerbation. If there is no sputum, and no signs of infection clinically it may be non-infective. The main difference between the two types of exacerbation is that antibiotics are not required if it is non-infective. 3. Body of Guideline COPD is a common, usually smoking related lung disease, which causes progressive breathlessness and in about 40% of patients chronic bronchitis as well.
Patient admitted to ED/AMU with suspected exacerbation of COPD
Investigations to confirm exacerbation of COPD
Prescribe oxygen and target saturations of 88-92% within an hour
Prescribe steroids, nebulisers +/- antibiotics within 4 hours
If saturations are <94% after an hour of medical therapy perform ABG
If patient has respiratory acidosis commence NIV via respiratory physiotherapist on-call
If patient is to be admitted put on respiratory PTWR list*
If patient can go home complete the discharge care bundle prior to signing off eTTO
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3.1 Ensure the diagnosis of COPD exacerbation is correct
Symptoms and signs of COPD exacerbation o Worsening of cough o Worsening dyspnoea o Wheezing o Increase in sputum volume, tenacity (difficult expectoration) and purulence o Acute confusion o Pyrexia o Tachypnoea o Tachycardia o Prominent abdominal movement o Pursed lip breathing, tracheal tug, prolonged expiration o Predominant use of accessory muscles o Inspiratory or expiratory wheezes o Look for signs of cor pulmonale (peripheral oedema, raised jugular venous
pressure) o Look for signs of type 2 respiratory failure (drowsiness, confusion, cyanosis,
flapping tremor) CXR – if pneumonia is present it is not a COPD exacerbation, even if they have
COPD. This will also help to exclude pneumothorax and heart failure as a cause for the patient’s presentation
ECG – exclude arrhythmias and MI, both very common in COPD
Bloods – send FBC, CRP, U&E
Sputum – send sputum culture
Check if spirometry has been done o Look on icare under respiratory tab newer lung function will appear here o Look on icare under letters seek respiratory consultant names o Look in GP letter o If a diagnosis of COPD has never been formally made a plan for spirometry
and respiratory review via the COPD clinic should be made if you think this is the patient’s underlying disease. If you plan to discharge the patient send a referral to the COPD clinic via the respiratory secretaries to enable the clinic booking. You should also be cautious about prescribing lots of drugs for the patient to go home on – in general the only maintenance inhaler appropriate at this stage is a LAMA, if they are unable to cope on SABA alone. See the COPD management and prescribing guideline for extra help.
Calculate the DECAF score if this is a COPD exacerbation; this helps to determine risk of inpatient mortality and therefore aid decisions about level of monitoring
3.2 Assess & prescribe oxygen within an hour Check saturations.
o If <94% ABG o If >94% & no clinical concern re: hypercapnia then ABG is not needed
Prescribe oxygen if saturations <92%, with target of 88-92%. Choose the flow that the patient needs to achieve this range.
3.3 Administer steroids and nebulisers within 4 hours
30mg prednisolone stat 2.5mg salbutamol + 500mcg ipratropium stat Prescribe the above qds as well; if patient is on LAMA then pause whilst on
ipratropium Prescribe salbutamol 2.5mg prn as well
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If sputum is purulent or signs of infection add doxycyline 200mg stat then 100mg od to complete a 7 day course. Alternatives include amoxicillin 500mg tds or a macrolide
3.4 Respond to respiratory acidosis/deterioration
If saturations remain <94% and ABG shows respiratory acidosis after 1 hour of medical therapy then patient should be started on NIV
o Contact respiratory physiotherapist on-call o If at BHH and it is between 8:30am-9pm contact respiratory SpR on-call as
well If the patient is clinically deteriorating but not acidotic an aminophylline infusion is an
option, but care should be taken as this is a potentially harmful drug. Start with a loading dose of 250mg, if the patient is not normally on oral theophyllines, then infuse at 0.5mg/kg/hr. Cardiac arrhythmias can occur and levels should be checked within 48 hours of starting the drug.
3.5 Add to respiratory post take list
This applies at BHH only. At Solihull the patient should be made known to the respiratory CNS by telephone. At GHH they should be managed via the general medical take list and the CNS informed.
3.6 Complete the discharge bundle If patient is going home without respiratory CNS review please consult discharge care
bundle before completing eTTO. This can be found on the COPD web page (see COPD on intranet) and is shown in the appendix. If you are a new foundation doctor it is in the package of information cards provided to you on starting. It is also on eMapp.
Print off the COPD self management information from the Patient Information tab in icare or Respiratory web page and ensure that this accompanies the eTTO. The only exception to this is if you have seen a copy of an existing self management plan that the patient uses in the community. Good self-management of the disease may help to avoid future admissions.
If you get stuck contact the relevant site specific COPD nurse
If the patient does not have spirometrically confirmed COPD and they have not seen a respiratory physician during this admission please consult the prescribing guideline before writing the eTTO. It is unlikely they should be on any maintenance drugs other than a long acting anti-muscarinic inhaler 4 Reason for Development of the Guideline This guideline was developed from national guidance issued by the British Thoracic Society and in response to results from implementation of a care bundle for COPD. 5 Methodology This guideline was developed from the British Thoracic Society (BTS) guidelines and developed via the Respiratory Directorate meeting. 6 Implementation in HEFT & Community This is intended for general use by all staff. The guideline will be promoted via the respiratory directorate meeting, 4 monthly departmental teaching sessions to junior doctors,
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emails to core medical trainees and promotion via posters in AMU and discussion with ED staff. 7 Monitoring & Suggested Quality Standards The guideline is monitored by monthly data collection for a CQUIN in 2015-16, and thereafter will be monitored via the national COPD audit, selected national and local audit standards are shown below
Standard Target Seen by respiratory team 100% Disease confirmed by spirometry 90% Self management plan at discharge 90% Smoking cessation advice if applicable 90% Inhaler technique checked 100% Pulmonary rehabilitation referral if eligible 70% Definite post admission review plan made 80%
8 References
NICE guideline 2010: http://guidance.nice.org.uk/CG101 NHS evidence update 2012: www.evidence.nhs.uk/evidence-update-5 COPD care bundles: http://thorax.bmj.com/content/early/2015/07/21/thoraxjnl-2015-
206833?papetoc DECAF score: http://thorax.bmj.com/content/67/11/970.abstract?sid=d3a896c7-
a0c6-4c8f-9b1f-f2505885e285
COPD DISCHARGE CHECK
• Discuss all prescribed medication
• Observe patient taking inhalers. If unsure on how to educate on technique talk to
ward pharmacist or CNS & find the next inhaler technique drop in session online
Medication &
inhaler technique
• If patient smokes discuss methods of smoking cessation, prescribe NRT or
varenicline on discharge, and refer to community smoking cessation teamSmoking cessation
• Issue written self management information
• If >2 exacerbations in last 12 months
advise to see GP to discuss getting a rescue pack of antibiotics and steroids. Document that we
recommend issuing this in the eTTO.
Self-management
plan
• If unable to walk 200m when well without stopping and has not been to
rehabilitation before refer via [email protected]
• Put 'PR referral for COPD discharge' in header and include diagnosis, FEV1 and MRC score. You
can refer without an FEV1 if it is not yet available.
Pulmonary
rehabilitation
• Inform COPD CNS of discharge date and patient's phone number
• Arrange COPD clinic or usual COPD team review in 6 weeks via CNS or phone to
usual team respectivelyFollow up plan
COPD DISCHARGE CHECKLIST
Place sticker here
Discuss all prescribed medication
Observe patient taking inhalers. If unsure on how to educate on technique talk to
ward pharmacist or CNS & find the next inhaler technique drop in session online
If patient smokes discuss methods of smoking cessation, prescribe NRT or
varenicline on discharge, and refer to community smoking cessation team
Issue written self management information - see respiratory web page to obtain
If >2 exacerbations in last 12 months AND you feel patient is capable of recognising exacerbations
advise to see GP to discuss getting a rescue pack of antibiotics and steroids. Document that we
recommend issuing this in the eTTO.
If unable to walk 200m when well without stopping and has not been to
rehabilitation before refer via [email protected]
Put 'PR referral for COPD discharge' in header and include diagnosis, FEV1 and MRC score. You
can refer without an FEV1 if it is not yet available.
Inform COPD CNS of discharge date and patient's phone number
Arrange COPD clinic or usual COPD team review in 6 weeks via CNS or phone to
usual team respectively
[email protected] Extension 43314 Bleep 2461
Observe patient taking inhalers. If unsure on how to educate on technique talk to
ward pharmacist or CNS & find the next inhaler technique drop in session online
If patient smokes discuss methods of smoking cessation, prescribe NRT or
varenicline on discharge, and refer to community smoking cessation team
see respiratory web page to obtain
you feel patient is capable of recognising exacerbations
advise to see GP to discuss getting a rescue pack of antibiotics and steroids. Document that we
If unable to walk 200m when well without stopping and has not been to
rehabilitation before refer via [email protected]
Put 'PR referral for COPD discharge' in header and include diagnosis, FEV1 and MRC score. You
Inform COPD CNS of discharge date and patient's phone number
Arrange COPD clinic or usual COPD team review in 6 weeks via CNS or phone to
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Meta Data Guideline Author: Alice Turner Guideline Sponsor: Jo Whitehouse Date of Approval: 12/10/15 Approved by: Alice Turner Date of CGG Ratification: The date that the Guideline was ratified by the Clinical Guideline Group Date of Launch: 13/10/2015 Review Date: 13/10/2018 Key Words COPD, exacerbation, oxygen, NIV Related Policies / Topic / Driver
COPD diagnosis and management guideline Emergency oxygen guideline
Revision History Version No Date of Issue Author Reason for Issue
2.0 Alice Turner Update 3.0 13/10/15 Alice Turner Update
Clinical Director: Signed…………………….………..
Name……………………………….
Date…………………………………