Acute exacerbations
An acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a serious event which can:
- Require hospital admission
- Accelerate the progression of the disease
- Reduce lung function
- Increase mortality
- Affect quality of life and functioning
- Worsen existing co-morbidities
This means that prompt identification of an exacerbation is key, so that treatment can be started as soon as possible.
It is important that patients can be seen face to face to assess the severity of their exacerbation and identify any other causes for their symptoms. Co-morbidities in patients with COPD are common.
Conditions which may present with similar symptoms to an acute exacerbation include:
- Pneumonia
- Pulmonary embolism
- Pneumothorax
- Acute heart failure
- Pleural effusion
- Cardiac ischaemia or arrhythmia
- Lung cancer.
- Upper airway obstruction
Patients with asthma and COPD
If your patient has a diagnosis of asthma, or presents with symptoms suggestive of asthma, see our Uncontrolled Asthma in Adults page for advice on how they should be treated.
Assessing severity
NICE defines an acute exacerbation as: a sustained worsening of a person's symptoms from their usual stable state (beyond normal day-to-day variations) which is acute in onset.
Each person living with COPD will experience an exacerbation differently. Exacerbations can have a gradual or rapid onset. Common symptoms include:
- Worsening breathlessness
- Cough
- Sputum production that increases and/or changes colour
- Wheeze
- Feeling generally unwell.
It is important that patients can be seen face to face to assess the severity of their exacerbation and to identify any other causes for their symptoms.
GOLD (2024) recommend the use of the ROME criteria to assess your patient and determine the severity of their exacerbation. ROME uses a visual analogue scale to assess dypnoea rather than the mMRC scale.
Mild or moderate exacerbations are more likely to be to be treated in the community. NICE suggest additional factors to consider when deciding where to treat the person with COPD.
| ROME Scale | ||
|---|---|---|
| Mild | Moderate | Severe (requires hospitalisation) |
| Dyspnoea score <5 Respiratory rate <24 Heart rate <95 02 sats >92% on air CRP <10mg/ml |
Respiratory rate >24 Heart rate >95 02 sats >92% on air CRP >10mg/ml No acidosis on ABGg |
As per moderate with worsening hyercapnia and acidosis |
© 2023, 2024, Global Initiative for Chronic Obstructive Lung Disease, available from www.goldcopd.org, published in Deer Park, IL, USA.
Community treatment of AECOPD
If your patient is treated in the community, first of all advise:
- Increase their short acting bronchodilator (via spacer if they have a pMDI) to 1-2 puffs hourly for 2-3 doses then every 2-4 hours based on response.
- Check their inhaler technique to ensure it is correct.
If there is no improvement, give
- 30mg - 40mg Prednisolone for 5 days.
If sputum is purulent in addition to increased volume and breathlessness, give
- Antibiotics for 5 days, as per local microbiology guidance.
- Patients with bronchiectasis will need a sputum sample sent off and a 14 day course of an appropriate antibiotic.
Sending sputum samples for culture is not recommended in routine practice, but may be appropriate of your patient has persistently purulent sputum.
Ensure that your patient knows what to do if they are feeling worse or have new symptoms. Patients should be reviewed, either face to face or by phone after 48 hours to ensure they are starting to recover.
An acute exacerbation of COPD lasts on average 11-13 days , so it is important to reassure your patient that they should not expect to feel fully recovered after the 5 days of steroid and/or antibiotic therapy.
Sometimes patients may ask for more Prednisolone or antibiotics but evidence does not support the use of further or extended courses, so it’s important to reassess them fully.
Rescue packs
It may be appropriate for your patient to have a rescue pack of Prednisolone and antibiotics at home.
For some patients, it may be more appropriate that they are assessed during an exacerbation before issuing any medication. This is especially important if you are concerned about them using it at the right time for the right symptoms, especially if they have co-morbidities which might mimic an exacerbation.
It is vital that rescue packs are only issued to patients who have sufficient support and education to use them correctly. This is to avoid the side effects of over use of Prednisolone and reduce antimicrobial resistance.
Examples of patients who may be suitable for rescue packs include those who:
- Have had an exacerbation in the past year and
- Have a self-management plan with clear instructions for when to use their Prednisolone, their antibiotics or both
- Are confident to start their rescue pack, and know how to take it correctly
- Know to inform their HCP that they have started their rescue pack within 48 hours of starting it
- Are aware of what to do if they are feeling worse or have new symptoms
Ensure that rescue packs are not on repeat prescription.
Post exacerbation review
Reviewing your patient following their exacerbation is important to identify any possible causes, reinforce education, self management and lifestyle strategies and change treatment if necessary.
Structure your review using the guide below.
| Action | Rationale |
|---|---|
|
Ask how your patient is feeling now. History leading up to recent exacerbation Record their CAT and mMRC score |
This gives you the opportunity to address any fears and concerns about recovery and helps identify any new or increased symptoms. – did patient act promptly? To find out if your patient recognised and treated their exacerbation promptly.
This will indicate their current health status and any areas in which they need additional treatment or support. |
| Check heart rate, blood pressure and BMI | To identify any comorbidities following exacerbation, such as hypertension, atrial fibrilation, cor pulmonale, heart failure. |
| Review treatment |
You may need to recategorise your patient using the ABE assessment tool and adjust their medication accordingly. Treat any new or increased symptoms. |
| Check inhaler technique and adherence | Ensure that your patient is able to use their inhaler device, understands when to use it and is taking it as prescribed. |
| Check smoking status and offer support | Smoking cessation should be offered at every contact and your patient might be motivated to quit after having had an exacerbation. |
| Refer pulmonary rehabilitation if indicated | Your patient might accept a referral if they have previously declined, or will benefit from PR. |
| Check vaccinations | Give any missed vaccinations opportunistically. |
| Check vitamin D levels | Low vitamin D is associated with moderate/severe exacerbations. |
| Check oxygen saturations | To identify if your patient needs to be referred for an oxygen assessment. |
| Ask about mental health | An exacerbation can be a very frightening experience. Identify if your patient is struggling with low mood or anxiety. |
| Ask about their social situation | To identify if they have any care needs due to change in their physical condition. Refer to social prescriber if necessary. |
For more in depth information on managing acute exacerbations watch these webinars from Rotherham Respiratory and the PCRS.