COPD exacerbation — acute management

PLAB 2 & PRES 3 · respiratory · hard · 8 minutes

Candidate brief

You are an FY2 doctor/SHO in the Emergency Department. Mr Robert Hughes, 68, has COPD and has developed worsening breathlessness, cough and sputum production over 3 days. Current observations: respiratory rate 30 breaths/min, oxygen saturation 82% on air, heart rate 112 beats/min, blood pressure 138/82 mmHg and temperature 37.9°C. Assess him, explain your concerns and initiate immediate management. Verbalise all examinations, investigations, treatments and escalation steps you would undertake.

What examiners look for

A COPD exacerbation is an acute worsening of breathlessness, cough or sputum beyond the patient’s normal variation. Do not withhold oxygen from a hypoxaemic patient. Give controlled oxygen and target SpO₂ 88–92%, because excessive oxygen can worsen carbon-dioxide retention and respiratory acidosis. Obtain an arterial blood gas in patients admitted to hospital with a COPD exacerbation and document the inspired oxygen concentration. Repeat the ABG after treatment or if the patient deteriorates. Give short-acting bronchodilators. In a hypercapnic or acidotic patient, drive nebulisers with compressed air and provide controlled oxygen separately. Offer oral prednisolone 30 mg daily for 5 days unless contraindicated. Antibiotics are not required for every exacerbation. Consider them when sputum becomes purulent, especially when sputum volume or breathlessness has also increased. Persistent acidotic hypercapnic respiratory failure despite optimal medical treatment requires urgent NIV assessment in a monitored setting with appropriately trained staff. Always consider alternative or additional diagnoses, including pneumonia, pneumothorax, pulmonary embolism, heart failure, ACS and sepsis.

Guideline references

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