CLINICAL GUIDELINE FOR THE MANAGEMENT OF ACUTE EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE ‘COPD’ 1. Aim/Purpose of this Guideline The guidance provides advice on the diagnosis of COPD and the management of acute exacerbations of COPD. 2. The Guidance 2.1. Working definition of COPD 2.2. Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking.  Airflow obstruction is defined as a reduced forced expiratory volume in 1 second (FEV1) and a reduced FEV1/FVC ratio (where FVC is forced vital capacity), such that FEV1 is less than 80% predicted and FEV1/FVC is less than 0.7.  The airflow obstruction is due to a combination of airway and parenchymal damage.  The damage is the result of chronic inflammation which is usually the result of tobacco smoke and which differs from the inflammation seen in asthma.  Significant airflow obstruction may be present before the individual is aware of it. 2.3. Severity of COPD depends upon more than just the severity of airflow obstruction but this is a reasonable surrogate. Severity grading has been recently updated (NICE CG101 2010) to bring into line with other international guidelines.     Stage 1 – mild FEV1 > 80% predicted; FEV1/FVC <0.7 and symptomatic Stage 2 – moderate FEV1 50- 79% predicted; FEV1/FVC <0.7 Stage 3 – severe FEV1 30- 49% predicted; FEV1/FVC <0.7 Stage 4 – very severe FEV1 <30 predicted; FEV1/FVC <0.7 or as per stage 3 plus respiratory failure 2.4. The presence of atypical features such as absent/weak smoking history, marked nocturnal symptoms or diurnal variation or a very productive cough should prompt consideration of alternative diagnoses such as asthma or bronchiectasis. 2.5. Definition of Exacerbation of COPD Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Page 1 of 9 2.6. An exacerbation is a sustained worsening of the patient’s symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. 2.7. Symptoms include:            Increased dyspnoea Increased sputum purulence Increased sputum volume Increased cough Upper airway symptoms (e.g. colds and sore throats) Increased wheeze Chest tightness Reduced exercise tolerance Fluid retention Increased fatigue Acute confusion 2.8. Investigations          Pulse oximetry to assess oxygenation Arterial blood gases should normally be measured to determine the presence or absence of both hypercapnia and acidosis. Inspired oxygen should always be recorded. CXR FBC, U&E’s, liver profile ECG Sputum Theophylline level should be measured in patients taking theophylline therapy on admission. Spirometry should be performed before discharge to confirm airflow obstruction and assess its severity unless it has already been reliably documented. Peak flow should be monitored if there is any suspicion of reversible airways disease i.e. asthma. 2.9. History 2.10. Record:  symptoms functional capacity when well using the MRC dyspnoea scale: o Grade 1: Not troubled by breathlessness except on strenuous exercise. o Grade 2: Short of breath when hurrying or walking up a slight hill. o Grade 3: Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace. o Grade 4: Stops for breath after walking about 100m or after a few minutes on level ground. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Page 2 of 9 o Grade 5: Too breathless to leave the house, or breathless when dressing or undressing.        Frequency of exacerbations. Previous admissions with COPD. Previous episodes of ventilation (both NIV and intubation). Usual treatment including oxygen (specifying whether short burst, portable, long term i.e. 16 hours per day or a combination of oxygen treatments). Concurrent illnesses (co-morbidities are common in these patients). Check for previous blood gas and lung function results. Record smoking history 2.11. Examination       Respiratory rate. Use of accessory muscles or paradoxical chest wall movements. Oxygen saturation and FIO2 Signs of hypercapnoea (warm peripheries, bounding pulse, flap, confusion). Cor pulmonale (peripheral oedema). Heart rate and rhythm. 2.12. Treatment     Treat hypoxia and respiratory failure Treat bronchospasm and obstruction Treat infection if present Smoking cessation advice 2.13. Treat hypoxaemia 2.14. Hypoxia should be treated according to the Trust’s Policy for the prescription and administration of emergency oxygen in adults (available via the Trust’s Document Library). 2.15. Patients who are known to, or are suspected of retaining CO2, should be given oxygen to achieve a target saturation in the range 88% to 92%. 2.16. Respiratory failure  Type 1 respiratory failure (pCO2<6.0kPa and pO2<8kPa) o These patients should have oxygen titrated to maintain target oxygen saturations in the range of 94% to 98%.  Type 2 respiratory failure (pCO2>6.0kPa) o These patients should have oxygen titrated according to the Trust Policy to maintain oxygen saturations in the range of 88% to 92%. o Patients with type 2 respiratory failure and an acidosis (pH < 7.35) should be considered for non-invasive ventilation (NIV) if the acidosis persists despite maximum standard medical management. Non-invasive ventilation should normally be commenced within an hour if there is no improvement. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Page 3 of 9  Intubation and mechanical ventilation. o The appropriateness of escalation to invasive mechanical ventilation should be assessed and recorded at the initiation of NIV. o When there is uncertainty or the patient is to be denied invasive mechanical ventilation this should be discussed with the responsible consultant. o If escalation is deemed appropriate the Outreach ITU team should be involved at the earliest opportunity. o These treatment options should where possible be discussed with the patient.  Treat bronchospasm and obstruction  Nebulised beta 2 agonists (salbutamol 2.5-5 mg or terbutaline 5-10 mg) and ipratropium bromide 500 mcg 6hrly. 2.17. NOTE  The driving gas for nebulised therapy should normally be air.  If a patient is hypercapnic or acidotic the nebuliser should always be driven by compressed air, not oxygen (to avoid worsening hypercapnia and acidosis). If oxygen therapy is needed it should be administered simultaneously by nasal cannulae.  Patients should be changed to hand-held inhalers as soon as their condition has stabilised because this may permit earlier discharge from hospital.  Give steroids: 30-40 mg prednisolone po. 2.18. Treat infection 2.19. Antibiotics should be used to treat exacerbations of COPD if two of the following three conditions are met:    increased sputum volume increased sputum purulence increased breathlessness 2.20. Antibiotics should also be used if there is evidence of consolidation on the chest xray even in the absence of sputum production. 2.21. Antibiotics should be prescribed according to the Trust Antimicrobial Policy (available via the Trust’s Document Library). 2.22. Initial empirical treatment should normally consist of one oral antibiotic such as:  Doxycycline 200mg stat then 100mg daily for 5 – 7 days, or; Amoxycillin 500mg tds for 5 – 7 days  Clarithromycin 500mg bd can be used where there is intolerance to doxycycline or allergy to penicillin. 2.23. Where sputum cultures are available treatment should be guided by antibiotic sensitivities. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Page 4 of 9 2.24. Smoking cessation advice 2.25. All current smokers should be advised to stop smoking, offered nicotine replacement therapy and referred to the smoking cessation service. 2.26. Discharge planning 2.27. Ideally all COPD patients should be managed on the respiratory ward but when that is not possible they should be seen by the chest service. 2.28. Home oxygen treatment should not normally be started in the immediate aftermath of an exacerbation. Long term oxygen needs are better assessed in outpatients after about four weeks. 2.29. All first admissions with COPD should be followed up in the chest clinic. 2.30. Subsequent admissions can often be followed up in the community by the community based respiratory nurses who should receive a copy of the discharge summary of all patients admitted with COPD. 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared The process of care will be monitored. Dr I I Coutts and Dr J D Myers. 1. The National COPD audit proforma. 2. The proformas developed for the COPD bundles project. The COPD bundles project is ongoing and data is collected constantly at present. The National COPD audits occur every 2 or 3 years. We will pilot the audit form for the next National audit between 16 th and 30th September 2013. Reports will be sent to the audit committee. The respiratory physicians meet and examine all audit data monthly at our governance meetings and these are minuted. Recommendations will be reported to relevant managers and clinicians for implementation. The COPD bundles project requires constant monitoring of the process of care and the implementation of whatever changes are required in order to optimise of care. 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Page 5 of 9 Appendix 1. Governance Information Document Title Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Date Issued/Approved: 17th August 2013. Date Valid From: 17th August 2013. Date Valid To: 17th August 2016. Directorate / Department responsible (author/owner): Respiratory Medicine – Ian Coutts, Chest Physician. Contact details: 01872 252721. Brief summary of contents Advice on the diagnosis and management of acute exacerbations of COPD. COPD exacerbation, respiratory, antibiotics. RCHT PCT CFT  Suggested Keywords: Target Audience Executive Director responsible for Policy: Medical Director. Date revised: 17th August 2013. This document replaces (exact title of previous version): Acute exacerbation of chronic obstructive pulmonary disease ‘COPD’. Seen by all 5 chest physicians, senior nursing staff on Wellington Ward and a respiratory nurse specialist. Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Rowena Green. Name and Post Title of additional signatories None required. Signature of Executive Director giving approval Publication Location (refer to Policy on Policies – Approvals and Ratification): {Original Copy Signed} Internet & Intranet  Intranet Only Document Library Folder/Sub Folder Clinical/Respiratory. Links to key external standards None Related Documents: Antimicrobial Policy Policy for the prescription and administration of emergency oxygen in adults Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Page 6 of 9 Training Need Identified? No. Version Control Table Date Versio n No Summary of Changes 10 Jun 10 V2.0 Previous version history not known. 17 Aug 13 V3.0 Links updated. Reformat. Changes Made by (Name and Job Title) Ian Coutts, Chest Physician. All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Page 7 of 9 Appendix 2.Initial Equality Impact Assessment Screening Form Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: Acute exacerbation of chronic obstructive pulmonary disease ‘COPD’ Directorate and service area: Medicine Is this a new or existing Procedure? Existing Name of individual completing Telephone: 01872 252721 assessment: Dr I I Coutts 1. Policy Aim* To provide guidance in the diagnosis and management of acute exacerbations of COPD. 2. Policy Objectives* To improve the care of patients admitted with acute exacerbations of COPD. 3. Policy – intended Outcomes* Improved outcomes. 4. How will you measure the outcome? By audit. 5. Who is intended to benefit from the Policy? Hospital staff who use the guidance in their work and patients who are treated for exacerbations of COPD. 6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? No. b. If yes, have these groups been consulted? c. Please list any groups who have been consulted about this procedure. *Please see Glossary 7. The Impact Please complete the following table using ticks. You should refer to the EA guidance notes for areas of possible impact and also the Glossary if needed. Where you think that the policy could have a positive impact on any of the equality group(s) like promoting equality and equal opportunities or improving relations within equality groups, tick the ‘Positive impact’ box. Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box. Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Page 8 of 9 Equality Group Age Positive Impact Negative Impact No Impact √ Disability √ Religion or belief √ Gender √ Transgender √ Pregnancy/ Maternity Race √ Sexual Orientation √ Marriage / Civil Partnership √ Reasons for decision √ You will need to continue to a full Equality Impact Assessment if the following have been highlighted: A negative impact and No consultation (this excludes any policies which have been identified as not requiring consultation). 8. If there is no evidence that the policy promotes equality, equal opportunities or improved relations - could it be adapted so that it does? How? Full statement of commitment to policy of equal opportunities is included in the policy Please sign and date this form. Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ A summary of the results will be published on the Trust’s web site. Signed ________________________________________ Date _________________________________________ Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Page 9 of 9