As an FY1, you are unlikely to be expected to make decisions about long term COPD management therefore focus your efforts on learning how to deal with acute exacerbations.

Initial assessment
1. If a patient reports having a diagnosis of COPD it is worth asking a few questions to clarify the accuracy of the statement. It isn’t uncommon for patients to use asthma & COPD interchangeably.

• When the diagnosis was made (COPD is unlikely in younger patients)
• How the diagnosis was made (spirometry is essential to confirm airway obstruction)
• Who made the diagnosis (GP v secondary care. If the latter you may have access to test results and clinic letters etc to assist)
• Smoking history (NOT all smokers get COPD! Inhaling cannabis can cause significant emphysematous damage and is worth asking about).  
• Occupation – miners for example are at risk of airways disease.
• What treatment they are on (increasing overlap with COPD & asthma) and crucially if they are using it
• It is possible for patients to have both diagnoses

2. Once you have ascertained the patient has COPD remember to exclude other causes for the deterioration in their symptoms – they are at higher risk of pneumonia, LRTIs, pneumothoraxes, myocardial infarctions (they are smokers!) and thus also pulmonary oedema and other causes of SOB/cough. It isn’t unheard of for diagnoses such as heart attacks to be missed due to diagnostic bias. A quick systematic review is advisable.

3. Examination of your patient should focus on 3 elements:

• Features to confirm the diagnosis of an exacerbation of COPD
• Absence of features associated with your differentials
• Infective or non-infective
  • Change in sputum colour, inflammatory markers, consolidation on CXR can all help with differentiation

Initial treatment
Broadly speaking this includes the following:

Steroids: oral prednisolone 30mg (or 100mg hydrocortisone IV if too unwell or unable to take PO)
There is increasing evidence that not all patients with COPD will benefit from steroids, but might suffer significant side effects from repeated courses. Eosinophil levels are being used to differentiate – eosinophilia suggests patients should be steroid responsive. As an FY1 please give the steroid and let your seniors decide on whether to continue.

Beta-agonist: nebulised salbutamol 2.5mg repeated every 20-30 min if needed.
Anti-muscarinic: nebulised ipratropium bromide 500micrograms (max QDS)

Controlled oxygen: not all patients with COPD need a lower target saturation of 88-92%. The lower target is for patients at risk of type 2 respiratory failure – previous NIV, home NIV, raised CO2.

Antibiotics: if the history, examination and test results suggest super-added bacterial infection.
Review recent sputum cultures for sensitivities and use antibiotics as per trust guidelines. Consult seniors/microbiology if unsure

Assessment & management of Type 2 respiratory failure

• This is an important part of managing an exacerbation of COPD. An arterial blood gas should be performed on patients who are hypoxic and requiring oxygen
  • A common oversight is attributing acidosis to COPD (diagnostic bias) when it is in fact metabolic. Some patients have a mixed picture
• If the patient has a respiratory acidosis (high CO2 and low pH) alert a senior as the patient may need ventilator support. 

BiPAP (NIV) and intubation are both an option depending on the severity of the acidosis, level of consciousness and the patients’ usual level of fitness.
If NIV is commenced it is important for decisions to be made on whether the patient is a candidate for intubation if they continue to deteriorate as well as resuscitation status.
These are NOT decisions you should be making as an FY1 but always clarify escalation plans with your seniors.

Escalation
Don’t be afraid to ask for help (registrar, critical care outreach, intensive care or other). In a life-threatening situation, it is not unreasonable to get help whilst carrying out your initial assessment and treatment. Be clear about why you are calling early, what you plan to do until they arrive and ascertain if anything further is required before assistance arrives.

Discharge
When caring for patients on the ward who have been admitted with an exacerbation of COPD your focus is now on ensuring they are improving and identifying when they are safe for discharge. Key elements will be:

• What the patient tells you!
• If the patient requires therapy only available in a hospital. Ie: Are they stable without nebulisers, off oxygen and intravenous therapies. 

Check if your Trust has specialist COPD nurses. They are a fantastic source of help and will usually want to review all patients admitted with an exacerbation. They assist with:

• Inhaler technique 
• Assessing if patients are on the appropriate level of therapy at home
• Accessing pulmonary rehab and smoking cessation services
• Arranging appropriate follow-up
• Early supported discharge (neb wean at home)
• Outpatient review/follow up or first people to call for admission avoidance

Even if you don’t have a specialist nurse the above aspects are key aspects of management so find out how to refer patients to smoking cessation services and pulmonary rehab. Check inhaler technique – Asthma UK has an excellent online resource with short videos demonstrating the correct technique for each inhaler type. The inhalers used for COPD are often the same so the website may still be useful.

Inhalers can be safely recycled to avoid entering a landfill. Encourage patients to locate the nearest pharmacy that provides this service.

By Dr Ruwani Rupesinghe (SpR)