Respiratory Disease - Advanced COPD: Treatment of exacerbations

Prevention or prompt treatment of COPD exacerbations is essential to stop further deterioration of the lungs, write Cherry Wynne and Rosaleen Reilly

COPD is a progressive, debilitating, chronic illness of the lungs. It is characterised by airflow obstruction which is usually progressive, not fully reversible and does not change markedly over several months.1

The main cause for COPD is smoking but it can also be caused by alpha 1 antitrypsin deficiency, occupational dusts and chemicals, and indoor and outdoor air pollution. Ireland has the highest death rate from respiratory disease in western Europe at over twice the EU average; in 1999 there were 7,158 respiratory deaths here – 26% were due to COPD.2

The nurse has a pivotal role to play in the management of advanced sufferers of this disease. The disease is characterised by exacerbations, which need to be either prevented or treated promptly and accurately to ensure they do not further accelerate the deterioration of the lungs.

Exacerbations frequently require hospitalisation for assessment and/or treatment. The need for hospitalisation increases the patient’s morbidity and mortality rates and has a negative effect on the patient’s quality of life, leading to high levels of anxiety and depression.3

While assessing a patient with advanced COPD, the nurse needs to incorporate a number of key points:

Spirometry is used to aid in the diagnosis of COPD and to classify its severity. A bronchodilatory reversibility test is done to outrule asthma. A chest x-ray is useful to exclude other respiratory diseases. An arterial blood gas is indicated in those with an FEV1< 40% predicted in order to outrule respiratory failure.4

The therapies available to those with advanced COPD are both pharmacological and non-pharmacological. Their aim is to improve and prevent symptoms, reduce the frequency and severity of exacerbations, improve health status, and improve exercise tolerance.

Pharmacological therapies
The Gold and NICE guidelines recommendations for the treatment of moderate to severe COPD is the use of a short-acting bronchodilator as well as a long-acting bronchodilator and inhaled glucocorticosteroid, if the patient is having repeated exacerbations.

If commenced, the NICE guidelines recommend the glucocorticosteroid be discontinued after four weeks, if it is not of benefit. Routine prescription of the combination therapy is only recommended if the patient has an FEV1  50% and two or more exacerbations in a 12 month period.

At present the TORCH study group is carrying out research into assessing the effect of inhaled corticosteroids and long-acting bronchodilators, alone or in combination, on mortality in patients with COPD.5 The results of this study are expected this year.

Both GOLD and NICE guidelines recommend assessment for long-term oxygen therapy if in respiratory failure. The guidelines also recommend that the pneumococcal and annual influenza vaccine be administered. Smoking cessation should be discussed and nicotine replacement therapy commenced if appropriate. Patients should be considered for suitability for surgery such as a bullectomy.

In end stage COPD, opiates can be used for the palliation of breathlessness which is unresponsive to other medical therapy. Benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen should also be used when appropriate. Palliative care teams should be involved at this stage.1

Non-pharmacological therapies
Self-management advice can assist patients to take control of their disease, by helping them to prevent or deal with their exacerbations promptly. Education regarding medication use, awareness of symptoms of deterioration and health promotion improves their ability to cope with their illness.

Pulmonary rehabilitation provides further education, exercise training and nutrition counselling and should be offered to all those whose quality of life is affected despite being on optimal medication.

Definition of an exacerbation
An exacerbation is an acute worsening of everyday symptoms. The patient may complain of worsening breathlessness, cough, increased sputum production and change in sputum colour. Most exacerbations are triggered by infection of the tracheobronchial tree or an increase in air pollution, however the cause for about one-third of exacerbations cannot be identified.

Management of exacerbations
Depending on the severity of the exacerbation the patient may be managed in primary care or referred to hospital. When deciding where to treat a patient the following considerations are taken into account:

In either case, the dose of short-acting bronchodilators is increased and, if not already used, an anticholinergic is added to the regime.

If commenced on nebules at this stage the patient should be restarted on inhalers as soon as possible. For those with hypercapnia, a compressor rather than oxygen should be used to give the nebuliser, with the use of nasal cannula simultaneously where oxygen therapy is required.

In all patients where the increase in breathlessness is affecting their daily activities of living, a course of oral steroids should be prescribed for seven to 14 days. If the sputum is purulent, if there is consolidation on the chest x-ray or if there are clinical signs of pneumonia, the patient needs to be commenced on antibiotics.

Where it is not possible to check an arterial blood gas, oxygen saturation should be checked. If neither are available and the patient is breathless, oxygen should be applied anyway and ABG and saturation checked as soon as possible. saturation should be maintained above 90% while observing for respiratory acidosis or worsening hypercapnia.

If despite optimal medical therapy the patient remains acidotic (PH < 7.35) non-invasive ventilation should be initiated.

Hospital-at-home and assisted discharge schemes
Studies6-9 have shown that hospital-at-home and assisted discharge schemes are a safe and effective way of treating certain patients with an exacerbation of COPD.

The exact criteria for those who are to follow this path would take into account the resources available in the community and any factors that may contribute to a worsening prognosis. Those involved in the service may include nurses, physiotherapists, occupational therapists and health care assistants.

Cherry Wynne and Rosaleen Reilly are respiratory nurse specialists in the Mater Hospital, Dublin
References on request

 Respiratory Disease - Advanced COPD: Treatment of exacerbations


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