COPD exacerbation and NIV

Question 1

What is an excerbation of COPD?

Answer 1

• Acute episodes
• Sustained worsening of COPD symptoms
  
  • ^eg. dyspnoea; cough; sputum
• Beyond normal day-to-day variations

Question 2

Name two triggers for exacerbations of COPD

Answer 2

• Respiratory tract infections
  
  • Most commonly rhinovirus
• Smoking
• Environmental pollutants

Question 3

Give three symptoms of an exacerbation of COPD

Answer 3

• Worsening:
  
  • Dyspnoea
  • Cough
  • Sputum production; change in colour
• Other:
  
  • Increased wheeze; chest tightness
  • URT symptoms: ^eg. cold; sore throat
  • Reduced exercise tolerance
  • Ankle swelling
  • Fatigue
  • Delirium

Question 4

Provide two features suggestive of a severe exacerbation of COPD

Answer 4

• Marked dyspnoea and tachypnoea
• Pursed-lip breathing; use of accessory muscles at rest
• New-onset cyanosis; peripheral oedema
• Delirium; drowsiness
• Marked reduced in ADLs

Question 5

Request four investigations for an acute exacerbation of COPD

Answer 5

All acute exacerbations presenting to hospital:

• CXR
• ABG
• ECG: exclude comorbidities
• FBC; U+E; CRP
• Theophylline level: if on theophylline therapy
• Sputum microscopy/culture: if purulent
• Blood cultures: if pyrexic

Question 6

Outline the management of exacerbations of COPD

Answer 6

1. Salbutamol 5mg/4h + ipratropium 500mcg/6h
2. O₂ as needed: high flow, then titrate to target levels
3. 30mg PO prednisolone or 200mg IV hydrocortisone for 5/7
   
   • Consider PPIs and bisphosphonates
4. Chest physiotherapy: aid sputum expectoration
5. Consider
   
   • IV aminophylline
     
     • Frequent monitoring
   • NIV
   • ITU for invasive ventilation

Consider need for antimicrobials ^eg. amoxicillin

Question 7

What are the indications for acute non-invasive ventilation?

Answer 7

• COPD: either
  
  • pH <7.35; pCO₂ >6.5; RR >23
  • Persisting after bronchodilator and controlled O₂ therapy
• Neuromuscular disease: either
  
  • Respiratory illness w/ RR >20 if usual VC <1L
  • pH <7.35 and pCO₂ >6.5
• Obesity: either
  
  • pH <7.35; pCO₂ >6.5; RR >23
  • Daytime pCO₂ >6.0 and somnolent

Question 9

Give three contraindications for non-invasive ventilation

Answer 9

• Severe facial deformity
• Facial burns
• Fixed upper airway obstruction
• pH <7.15
• GCS <8
• Confusion; agitation
• Cognitive impairment

Question 10

Outline the discharge planning following exacerbation of COPD

Answer 10

• Spirometry prior to discharge
• Re-establish optimal maintenance bronchodilators
• Satisfactory SaO₂/ABG if episode of respiratory failure
• Medication review and education
• Consider follow-up and home care