COPD Exacerbation Pathway

About acute exacerbation of COPD

• Early detection and management of acute exacerbations may prevent progressive decline and reduce hospital admissions. It is important to educate patient, carers, and family about early detection.
• More than 80% of acute exacerbations can be managed without hospital admission.
• Frequent exacerbations accelerate a decline in lung function, further impair quality of life, restrict daily activities, and aggravate deconditioning.

COPD exacerbation:

• Acute change in the patient’s baseline dyspnoea, cough, wheeze and/or sputum that is beyond normal day-to-day variations.
• Cough increases in frequency and severity, sputum production increases in volume and/or changes character and/or dyspnea increases.
• More than 80% of acute exacerbations can be managed without hospital admission.

Consider hospital management if:

• Inadequate response to outpatient or emergency department management
• Onset of new signs (e.g. cyanosis, altered mental status, peripheral edema)
• Marked increase in intensity of symptoms over baseline (e.g. new onset resting dyspnea) accompanied by increased oxygen requirement or signs of respiratory distress
• Severe underlying COPD (e.g. forced expiratory volume in one second [FEV1] ≤50 percent of predicted)
• History of frequent exacerbations or prior hospitalization for exacerbations
• Serious comorbidities including pneumonia, cardiac arrhythmia, heart failure, diabetes mellitus, renal failure, or liver failure
• Frailty or insufficient home support

Initial Assessment

1. Confirm diagnosis of acute COPD exacerbation and (consider and exclude heart failure and pneumonia in assessment).
2. Assess drowsiness, confusion, change in dyspnea, deteriorating vital signs

Examination

• Check temperature, pulse rate, and respiratory rate, BP
• Measure pulse oximetry. Check pulse oximetry on the finger. Measure pulse oximetry for at least a minute before documenting the oxygen saturation, to allow the reading to stabilize. Compare recordings with stable baseline.
• Pulse Oximeter Patient Instructions (ProResp)
• Translated Pulse Oximeter Patient Instructions are available in Arabic, Bengali, Chinese (simplified), Dari, French, Hindi, Portuguese, Russian, and Spanish.
• Assess breathing
  • Should I use the Roth score? NO Click here for more detail.

1. Ask the patient (or caregiver) to describe the problem with their breathing in their own words, and assess the ease and comfort of their speech. Ask open-ended questions and listen to whether the patient can complete their sentences.
   • “How is your breathing today?”
2. Then specifically check symptoms.
   • “Are you so breathless that you are unable to speak more than a few words?”
   • “Are you so breathless that you need to pause when eating?”
   • “Are you breathing harder or faster than usual when doing nothing at all?”
   • “Are you so ill that you’ve stopped doing all of your usual daily activities?”
3. Focus on change. A clear story of deterioration is more important than whether the patient currently feels short of breath. Ask questions like:
   • “Is your breathing faster, slower or the same as normal?”
   • “What could you do yesterday that you can’t do today?”
   • “What makes you breathless now that didn’t make you breathless yesterday?”

Interpret the breathlessness in the context of the wider history and physical signs. For example, a new, audible wheeze and a verbal report of blueness of the lips in a breathless patient are concerning.

Check out this resource for information on conducting a remote assessment if an in-person assessment cannot be done. A video examination may help add key detail, if necessary.

Assess Context:

• Determine baseline functional status
• Ask if patient has an existing COPD Action Plan
• Assess social situation, e.g. lives alone (see exclusions).

Investigations:

2. Chest X-ray if signs suggest pneumonia, or if diagnosis is uncertain

Red flags indicating need for referral to ED

1. Respiratory failure, e.g. cyanosis, confusion
2. In patients not on home O2, a saturation of less than 88% AND a change of at least 3% from baseline. In patients on O2, an increase of 2 LPM or more required to maintain a saturation of greater than 88% at rest
3. Drowsiness
4. Deteriorating vitals, breathlessness, level of consciousness at 24 hours despite treatment
5. Not stable at 24 hours
6. No contact or home visit occurred within 24 hours
7. Patient or family desire to transfer to hospital
8. Failure to begin to respond to treatment after 24 hours
9. Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection. The qSOFA scale can be used for early identification:
   • Low blood pressure (SBP≤100 mmHg)
   • High respiratory rate (≥22 breaths per min)
   • Altered mentation (Glasgow coma scale <15).

1. If not already done and recorded, ask the patient and family about expectations and goals of care.
2. Look for acute plan or advance care plans in the patient’s health records. Consider: Patients with severe COPD with a short life expectancy, e.g. less than 1 year, should be managed conservatively. Invasive ventilation strategies (intubation) is usually not appropriate. Non-invasive ventilation, (examples: BiPAP, nasal CPAP) may be suitable if congruent with patient’s goals of care.

Following admission with an exacerbation, around 25% of patients will be readmitted within one month. Predictors of readmission are biopsychosocial in nature rather than medical, e.g. living alone, distance from family practice, poor community support.

1. Arrange follow-up about 1 week after exacerbation.
2. Review severity status and long-term management.
3. Reassure that recovery to reach baseline may take at least 30 days. In case of pneumonia, patients may still have symptoms at 6 weeks.
4. Early detection and management of acute exacerbations may prevent progressive decline and reduce hospital admissions. It is important to educate patient, carers, and family about early detection.
5. Review medications and inhaler technique.
6. Give patient education resources eg. Canadian Lung Association Complete COPD handbook
7. Consider referral for pulmonary rehabilitation (see below). Click here for a list of pulmonary rehab programs in the Hamilton area.
8. Consider spirometry (see below). Click here for information on spirometry testing in the Hamilton area.
9. If exacerbations are repeated despite this, consider additional testing.

Red flags: More serious signs include chest pain, blue lips or fingers, increasing breathlessness and decreasing pulse oximeter readings despite treatment, and confusion. If you have these signs, call 911 immediately or ask someone to take you to the nearest emergency department. Do not drive yourself.

Give patient information on red flags to watch for and breathing techniques, such as this Patient Guide on COPD Exacerbations.

Visit this page for comprehensive patient resources for COPD.

• Request acute general medicine assessment (or acute respiratory assessment if under the current care of a respiratory physician) if:
  • any red flags
  • the patient cannot be managed at home despite community supports
  • patient frequently attends hospital (more than 2 admissions per year)
• If there is uncertainty about management or referral, or patient is acutely unwell, consider a phone discussion with an emergency department physician.

• Canadian Thoracic Society Clinical Practice Guidelines on:
  • Pharmacotherapy in patients with COPD
  • Managing dyspnea in patients with advanced chronic COPD