To be used in patients with confirmed COPD who have an acute exacerbation

Patient assessment
Symptoms Examination
Either of: - ABCDE
- Increased SOB - Look in particular for peripheral oedema,
- Increased wheeze cyanosis, drowsiness, and/or confusion as these
- Increased cough and/or sputum may indicate a severe exacerbation
production or purulence

-
Arrange Investigations - should not delay management
- ABG - Ideally should be performed within 10 minutes of arrival to ER in a severely
breathless patient. Should be repeated within 15-30 minutes if there is a change in FiO₂
- CXR
- Bloods including FBC and U+Es
- ECG
- Cultures - Sputum +/- Blood (if pyrexial)

Management
- Controlled oxygen. Give lowest FiO₂ needed to keep saturations 88-92%. Start with 28% and
titrate as needed
- Nebulised Salbutamol 5mg and Ipratropium 500mcg. In those at risk of hypercapnic
respiratory failure use compressed air to drive nebuliser with supplemental O₂ given by nasal
cannulae
- Corticosteroids. Prednisolone 30mg PO / Hydrocortisone 100-200mg IV in severe exacerbation
- Consider Antibiotics. These should be used if history of more purulent sputum, clinical signs of
pneumonia or consolidation on CXR
- Consider IV Fluids, diuretics, aminophylline if indicated
- Consider need for respiratory support (see below)

NIV / Intubation? Respiratory failure

Oxygen to maintain Saturations 88-92% Type I = PaO₂ < 60mmHg, PaCO₂ < 50mmHg
Obtain ABG
Ensure PaO₂ > 60mmHg Type II = PaO₂ < 60mmHg, PaCO₂ > 50mmHg
Is PaCO₂ > 50mmHg

No - No change Yes - pH < 7.35 (with PaO₂ > 60mmHg) despite maximal medical
Continue as above treatment

No - No change Yes - Consider NIV or Intubation

Continue as above

ABGs should be repeated every hour until the patient is stable or more frequently if there is
deterioration in clinical condition and within 15-30minutes if there is a change in FiO₂

Dr. Dayaram Lamsal, Dr. Thomas Barker (UK), Dr. Joanna Metcalf (UK) 2073. CMC ED
Adapted from European Respiratory Journal and NICE Guideline CG101, June 2010