Acute exacerbation of chronic obstructive pulmonary disease

Both Global Initiative for Chronic Obstructive Lung Disease (GOLD) and National Institute for Health and Care Excellence (NICE) guidelines stratify exacerbations into mild, moderate, and severe, based on the management required:[1]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report. 2023 [internet publication]. https://goldcopd.org/2023-gold-report-2 [90]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. July 2019 [internet publication]. https://www.nice.org.uk/guidance/ng115 [Figure caption and citation for the preceding image starts]: Assess severity to determine where and how to treat the patientCreated by the BMJ Knowledge Centre based on GOLD and NICE guidelines [Citation ends].

In hospitalised patients, assess the severity of the exacerbation using a prognostic score, such as DECAF (Dyspnoea, Eosinopenia, Consolidation, Acidaemia, and atrial Fibrillation) or BAP-65.[101]Echevarria C, Steer J, Heslop-Marshall K, et al. Validation of the DECAF score to predict hospital mortality in acute exacerbations of COPD. Thorax. 2016 Feb;71(2):133-40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4752621 http://www.ncbi.nlm.nih.gov/pubmed/26769015?tool=bestpractice.com [ BAP-65 prediction of in-hospital mortality and need for mechanical ventilation in COPD Opens in new window ]

• The score will indicate which patients are likely to benefit from early intervention, such as non-invasive ventilation.

Further stratify hospitalised patients based on their clinical signs.[1]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report. 2023 [internet publication]. https://goldcopd.org/2023-gold-report-2

• No respiratory failure

  • Respiratory rate 20-30 breaths/minute.

  • No use of accessory respiratory muscles.

  • No change in mental status.

  • Supplemental oxygen given via Venturi mask up to 28% to 35% inspired oxygen (FiO₂) restores oxygen saturations.

    • Ensure that there is no evidence of hypercapnia before moving to higher concentrations of oxygen.

    • Perform ongoing assessment of arterial blood gas (ABG).

    • Document the FiO₂ or O₂ flow rate.

  • No increase in PaCO₂.

• Acute respiratory failure – non-life threatening

  • Respiratory rate >30 breaths/minute.

  • Using accessory respiratory muscles.

  • No change in mental status.

  • Hypoxaemia improves when supplemental oxygen at higher concentrations is given via Venturi mask.

    • You must ensure that there is no evidence of hypercapnia before moving to higher concentrations of oxygen.

    • Perform ongoing assessment of ABGs.

    • Document the FiO₂ or O₂ flow rate.

  • PaCO₂ increased compared with baseline or elevated approximately 6.7 kPa (50-60 mmHg).

• Acute respiratory failure – life threatening

  • Respiratory rate >30 breaths/minute.

  • Using accessory respiratory muscles.

  • Acute changes in mental status.

  • Hypoxaemia not improved with supplemental oxygen via Venturi mask or increased FiO₂.

    • You must ensure that there is no evidence of hypercapnia before moving to higher concentrations of oxygen.

    • Perform ongoing assessment of ABGs.

    • Document the FiO₂ or O₂ flow rate.

  • PaCO₂ increased compared with baseline or elevated approximately 8 kPa (>60 mmHg) or acidosis present.