COVID-19 note

Nebulised treatments – Where practical , defer in favour of metered dose inhaler and spacer use, depending on patient tolerance and severity of exacerbation. Nebulised treatments are not on the list of aerosol-generating procedures (AGPs) by Public Health Ontario. Use contact and droplet precautions when providing nebulised treatments.

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
  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.

In addition, a video examination will add key detail such as whether the patient is blue, the extent of respiratory effort and the opportunity to count the respiratory rate.

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:

Consider:

*Note: lab work may not always be practical, and is not essential to proceed with treatment.

COPD exacerbations are usually associated with airway inflammation. This inflammation can be neutrophilic (usually triggered by viral or bacterial infection) or eosinophilic (allergic/asthmatic type inflammation). A high peripheral blood neutrophil count suggests possible bacterial bronchitis or pneumonia and may indicate the need for chest xray and/or antibiotics. A peripheral eosinophil count >300 cells/μLin a patient with repeated exacerbations suggest that long-term inhaled steroids may be of benefit in addition to oral steroids. Significantly elevated eosinphils should also lead to consideration of eosinophilic disease (most commonly eosinophilic asthma).

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.

If red flags, request acute general medicine assessment (or acute respiratory assessment if under the current care of a respiratory physician) unless the patient is being treated palliatively and symptoms can be managed in the community.

  • If no red flags decide whether the patient’s exacerbation can be managed in the community, considering other exclusion criteria for home-based management.

Social

  • Resides outside of area served by home care providers or outside of Hamilton hospital (HHS & SJHH) catchment area
  • Resides in a facility that provides onsite medical care (e.g. long-term care or rehab)
  • Not housed, or unstably housed
  • No access to phone
  • No working heat (October-April), no working air conditioning if forecast >27C (June-Sep)

Clinical

  • Acute delirium, as determined by the Confusion Assessment Method
  • Secondary condition requiring in hospital care.
  •  See Managing Progressive Life-limiting Conditions.
  • Cannot independently ambulate to bedside commode
  • As deemed by physician, patient likely to require any complex procedures (for example  computed tomography, magnetic resonance imaging)
  • For COPD: BAP-65 score >3 (hyperlink this and assume urea =0 unless dehydrated 9=1)

Other

  • Unable to consent (or no health care proxy present)
  • Under age 18

If the patient has end-stage COPD and their plan supports management at home, consider increasing nursing or palliative care involvement. See HFAM resources on Managing Progressive Life-limiting Conditions

If cannot be managed in the community refer to ED.

  1. Increase dose of bronchodilators.
  • Use 4 to 6 puffs MDI every 3 to 4 hours, using large volume spacer for best delivery.
  • Inhalers and spacers are as effective as nebulisers in mild to moderate exacerbations, and reduce droplet infection spread.

Nebulisers

  • In most instances, inhalers used with a spacer device will be sufficient to manage acute symptoms.
    • Nebulisers increase risk of COVID-19 infection to treating staff. If nebulisers are used, use contact and airborne precautions and clean the room thoroughly afterwards.
    • If using a nebuliser, avoid high flow oxygen in patients at risk of CO2 retention. There is a potential risk of droplet infection spread when using a nebuliser.
    • Do not use ipratropium if the patient is taking a long-acting muscarinic (LAMA).

If patient is using a dry-powder inhaler device, switch to an HFA inhaler as they may not have adequate respiratory effort to inhale adequate dose from D-PID.

If increase in sputum purulence and increase in sputum volume or breathlessness, give antibiotics.

Click here for a list of all inhaled drugs for COPD with dosing parameters and LU Codes

2. Oral antibiotics

  • Amoxicillin oral 500 mg three times a day.
  • If penicillin allergy:
    • doxycycline oral 200 mg on first day, then 100 mg daily; OR
    • azithromycin 500 mg daily. Note: check patient is not on other QT prolonging drugs
  • If the patient has not responded (treatment failure), consider amoxicillin + clavulanic acid oral 875 mg twice a day or a fluoroquinolone (e.g., levofloxacin 500 mg once daily for 7 days or 750 mg once daily for 5 days). Note: fluoroquinolones are no longer recommended for first line treatment because of side-effect concerns.
  • Usual duration is 5 days, depending on clinical response.

Consider atypical or resistant organisms.

Patients receiving frequent courses of antibiotics may acquire resistant organisms (such as penicillin resistant pneumococci), or become colonised or infected with less common organisms, e.g. Pseudomonas aeruginosa, Stenotrophomonas maltophilia.

  • Consider sputum testing if patients do not seem to respond to a course of antibiotics. See patient information for sputum collection.
  • Aspergillus commonly can be isolated during or after courses of antibiotic therapy and is significant only if isolated repeatedly or if fungal hyphae are seen on microscopy.
  • If requested, non-tuberculous mycobacteria may be isolated. The significance of single isolates is often unclear. Repeat sputum testing in the first instance. Consider seeking written specialist advice.

Click here for a list of all oral antibiotics for acute COPD exacerbations with dosing parameters and LU Codes

3. Oral prednisone

Start oral prednisone if: moderate to severe exacerbation or symptoms worsening in spite of antibiotics and increased bronchodilators.

  • Prednisone 50 mg daily for 5 days.
  • Dose tapering is not needed for short courses.
  • Average time to recover from an acute exacerbation is 30 days. Longer courses of oral steroids do not help this recovery.
  • Do not increase inhaled steroid dose.
  • Long-term use of oral steroids is not recommended.
  • The Canadian Thoracic Society recommends that exacerbation management for COPD be continued according to regular treatment guidelines for steroid use, despite COVID-19. 

Click here for a list of all oral medications for COPD with dosing parameters and LU codes

4. Patient advice

Set expectations with patient about likely duration of the course of medications prescribed as well as illness course (see section 6. Follow-Up).

Air motion in the room (e.g. blowing air from a fan) can also help with dyspnea. See patient information sheet in Section 5. Patient Advice for other advice including red flags.

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.

5. Coexisting conditions

Optimize treatment of coexisting conditions, e.g. heart failure, pneumonia.

6. Monitoring

Arrange active follow-up appointment(s) to assess response to treatment as well as red flags. Increase frequency of monitoring and aggressive treatment if patient has new or increased oxygen desaturation on exercise.

Oxygen providers have indicated that they can rapidly initiate in the home, including weekends. Respiratory therapists are available for in-home assessment.

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.

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.

Click here for a list of pulmonary rehab programs in the Hamilton area

A pulmonary rehabilitation program is individually-tailored, and includes exercise and education for patients with chronic lung disease. It is designed to optimise physical and social performance and support and maintain autonomy and there is good evidence that it can improve function, symptoms, quality of life and reduce hospitalisations.

Programs usually run multiple sessions over 2-3 months.

A multidisciplinary team provides an education and exercise program (e.g. Certified Respiratory Educator, Counsellor, Dietitian, Kinesiologist, Occupational Therapist, and/or a Physiotherapist).

The program covers: learning about their lung condition, how to manage their symptoms, smoking cessation support, how to prevent hospitalizations and visits to the emergency department. It also helps patients learn how to conserve energy in order to improve quality of life, and provides peer support.

  1. First assess the FEV1/FVC and compare with threshold of 0.7 (or lower limit of normal in older adults – see table note*). If this is <0.7 or LLN then this is an obstructive defect.

Differential Diagnosis if FEV1/FVC is > 0.7 includes asthma, cardiovascular or pulmonary vascular disease, obesity, severe deconditioning, anemia, pulmonary fibrosis / interstitial lung disease, Neuromuscular disease, pleural disorders. See detailed spirometry interpretation tool.

2. Assess the FVC. If this is above the LLN, then you have excluded a restrictive defect. If it is below the LLN a restrictive pattern is suggested. Full lung function is indicated depending on the clinical situation (note that restrictive patterns seen on spirometry are correct only around 50% of the time).

3. Assess bronchodilator response. A >200ml AND >12% improvement of FEV1 and/or FVC is significant response.

4. Do the results confirm or exclude a diagnosis or COPD?

Classification of COPD Severity

1. By lung function testing:

ClassificationFEV1/FVC*FEV1
Mild< 0.7>80% predicted
Moderate< 0.750-79%
Severe< 0.730-49%
Very Severe< 0.7<30%
*Note in older adults compare the FEV1/FVC ratio with the lower limit of normal (LLN) in the spirometry result (LLN is defined as the 5Th percentile for age and height of patient). If the FEV1/FVC ratio is greater than LLN then spirometry os normal or a restrictive or other diagnosis below should be considered. Using a fixed ratio of 0.7 in older adults results in overdiagnosis of COPD.

2. By patient’s level of breathlessness

Grade*
1Not troubled by breathlessness except with strenuous exercise
2Troubled by shortness of breath when hurrying on the level or walking up a slight hill
3Walks slower than people of the same age on the level because of breathlessness OR has to stop for breath when walking at own pace on the level
4Stops for breath after walking about 100 yards (90 m) or after a few minutes on the level
5Too breathless to leave the house or breathless when dressing or undressing
*Medical Research Council (MRC) dyspnea scale
  • 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.