COPD: Acute Exacerbation

Key points

• Acute exacerbation of COPD: a sustained worsening of dyspnoea, cough and/or sputum beyond normal day-to-day variation; a common reason for hospital presentation.
• Features: increased dyspnoea, cough and wheeze; often increased sputum volume/purulence (suggesting infection); patients may be hypoxic and, if hypercapnic, drowsy or confused.
• Common bacterial causes: Haemophilus influenzae (most common), Streptococcus pneumoniae and Moraxella catarrhalis; many exacerbations are viral (e.g. rhinovirus).
• Management: controlled oxygen targeting SpO2 88-92% (start a 24-28% Venturi mask) with early ABG; nebulised salbutamol and ipratropium; oral prednisolone 30 mg once daily for 5 days; antibiotics only if sputum is purulent or there are clinical features of pneumonia (first-line amoxicillin, doxycycline or clarithromycin per NG114).
• Consider non-invasive ventilation (NIV) for persistent hypercapnic respiratory failure (respiratory acidosis, pH under 7.35 with raised CO2) despite optimal therapy; consider IV aminophylline only if the response to nebulisers is inadequate.