ACUTE EXACERBATION OF COPD MANAGEMENT:
In AMU or A&E during working hours, acute exacerbations of COPD should be discussed with respiratory nurse specialists. Contactable via these numbers:
- 07887 787959
- 07961 221848
- Bleep: 2086
- Bronchodilators should be delivered via nebuliser initially in the AECOPD driven by Air.
- Nebulisers and the driving gas should prescribed on EPMA
- Nebulisers should be driven at a rate of 7l/min of air
- Inhaler therapy should be reinstated as soon as the clinical condition allows
- Supplemental Oxygen during nebulisation can be given via nasal cannula if required
Nebulisers to give: 1) Salbutamol 2.5mg nebuliser driven by AIR QDS 2) Ibratropium bromide 500mcg driven by AIR QDS
STEROIDS: PO 30mg prednisolone for 5 days usually (patients who have already been on steroids via their GP/take steroids regularly, may require 40mg) Weaning prednisolone depends on the patient clinically - those who have required multiple steroids over a short time OR take low dose steroids long term, will need a slow weaning plan. The total course of steroid treatment should be 14 days.
ANTIBIOTICS: Antibiotics should be given to patients with; purulent sputum or evidence of consolidation/clinical signs of pneumonia in the absence of purulent sputum. UCLH guidance:
- Amoxicillin 500mg PO TDS (5/7). Doxycycline 200mg PO stat, then 100mg PO BD if penicillin allergic
IF patient has not responded to these in the last four weeks, then:
- 1st line: Doxycycline 200mg PO stat, then 100mg PO BD OR co-amoxiclav 625mg PO TDS
- Penicillin allergic: Ciprofloxacin 500mg PO BD 5/7
- This is a key part of management in acute exacerbations. Contact physiotherapy to help clear sputum.
OXYGEN: Oxygen should be prescribed on EPMA with target saturations & clearly stated on the NEWS chart. 88-92% where patients are retaining carbon dioxide
NON INVASIVE VENTILATION:
- NIV should be used in patients with persistent hypercapnia despite optimal medical therapy
- NIV should be delivered on T8/AMU/ITU with staff trained to use and set up NIV machines
- There should be a clear plan when starting NIV, including treatment escalation plan should NIV fail to work/clinical deterioration in patient.
INVASIVE VENTILATION AND INTENSIVE CARE:
- Where appropriate, patients may requrire invasive ventilation or ITU treatment. If patients are not responding to NIV and treatment needs to be escalated, contact PERRT (#3301/3302), ITU (07939135452) and the registrar/consultant caring for the patient.
- CXR - to assess for consolidation
- ABG - noting down the oxygen given if any
- ECG - rule out other co-morbidities
- Bloods - FBC, U&Es, theophylline level (if patient on theophylline)
- Sputum - send for MC&S
- Blood cultures - if pyrexial
- Clinical assessment - sputum production/colour, chest signs, mobility
- Oxygen - Oxygen saturations and oxygen requirements.
- ABG intermittently
- Patients should be restarted on their optimal bronchodilator therapy
- Patients who have had respiratory failure, should have ABG to show improvement
- Care assessment should be made
- Follow up (in community or clinic), should be arranged
CHRONIC MANAGEMENT: These are a list of things to consider in managing stable COPD patients
- Smoking history should be assessed when these patients present to you, and cessation advice should be given
- Nicotine patches: need to complete
- Nicotine medicated chewing gum - patients smoking <20/day should use 1 piece of 2mg strength gum when they have the urge to smoke/prevent cravings. For those smoking >20/day - they should use 4mg strength (no more than 15 pieces a day)
- Nicotine inhalation cartridge - prescribe as 10mg (max 12/day) or 15mg (max 6/day)
- Nicotine lozenge - patients smoking <20/day, should use lower strenth, those smoking >20/day, will need a higher strength.
SHORT ACTING BETA2 AGONISTS AND SHORT ACTING MUSCARINIC ANTAGONISTS (SABA/SAMA) Used for initial treatment for relief of breathlessness
- SABA - salbutamol [Ventolin 100-200mcg (1-2puffs)] PRN upto 4 times a day
- SAMA - ipratropium [Atrovent 20-40mcg up to 4 times a day]
- Budesonide [Pulmicort 100-800mcg BD]
- Fluticasone [Flixotide 100-500mcg BD]
- Beclometasone [Qvar 200-400mcg BD]
LONG ACTING BETA AGONIST
- Salmeterol - Serevent [50mcg BD]
LONG ACTING MUSCARINIC ANTAGONIST
- Trotropium - Spiriva [18mcg OD]
INHALED COMBINATION THERAPY
- Combivent - salbutamol and ipratropium [1vial (2.5mL 3-4 times a day)]
- Symbicort - Budesonide and formoterol [200/6 2 puffs BD]
- Seretide - Fluticasone and salmeterol [seretide 50 2 puffs BD, seretide 125 2 puffs BD, seretide 250 2 puffs BD]
- Hand-held inhaler devices are usually an optimal way to administer bronchodilator therapy
- Patients should receive training to use the device
- Patients who find it difficult to use inhalers alone, should be given spacers
- Prescribed on EPMA by typing SPACER in the free-text section
- Patients with unmanageable breathlessness despite inhaler therapy should be considered for nebulisers.
- Regular assessment should be made as an outpatient to assess if the nebuliser therapy is helping, discontinue if there is no clinical improvement.
- If considering starting a patient for nebulised therapy, respiratory clinical nurse specialists should be able to help provide equipment, servicing, advising and supporting the patient.
- In patients with advanced COPD, low dose long term steroids may be required. Consideration of starting this will be a senior decision.
- This should only be considered after a trial of SABA and LABAs, or patients unable to use inhaled therapy.
- Theophylline levels will need to be checked regularly.
ORAL MUCOLYTIC THERAPY
- Carbocysteine 375mg - 750mg TDS [form needs to be filled out from insight to start people on this medication at UCLH]
- Consider in those with a chronic cough productive of sputum
OXYGEN LONG TERM OXYGEN THERAPY (LTOT)
- To be considered in patients with a PoO2 <7.3kPa when stable or PaO2 7.3 - 8kPa and one of; secondary polycythaemia, noctural hypoxaemia, peripheral oedema or pulmonary hypertension
- Patients should aim to use it at least 15 hours a day
- Patients being considered for LTOT need an oxygen therapy assessment by the respiratory clinical nurse specialists at UCLH.
- This is to be considered for those on LTOT who want to use oxygen therapy when outside their home, and in those who desaturate on exertion.
- This should also be assessed by the respiratory clinical nurse specialists at UCLH.
SHORT BURST OXYGEN THERAPY
- This should be considered in those who have episodes of extreme breathlessness not relieved by other medical therapy
- Asssesment should be made by respiratory clinical nurse specialists at UCLH.
- UCLH dose not provide long-term NIV, so referrals should be made to relevant hospitals:
- Royal Free - Guys and St Thomas
- Patients willing to engage in pulmonary rehabilitation should be referred via the community respiratory team - ask the respiratory clinical nurse specialists to help with this
- Annual influenza vaccination and pneumococcal vaccination shold be offered to all COPD patients
- Patients who are breathless, and have a single large bulla on a CT scan and an FEV1 less than 50% predicted should be referred for consideration of bullectomy