Management of COPD Exacerbation with Breathlessness

Initial Assessment

For patients presenting to the emergency room with breathlessness due to COPD exacerbation, assess airway, breathing, and circulation (ABC) first, followed by a focused history including exercise tolerance, current treatments, time course of exacerbation, and previous admissions 4
Document signs of infection, severe airway obstruction, peripheral edema, cyanosis, and/or confusion in patients with COPD exacerbation 5
Measure pulse and respiratory rate in all cases, and use pulse oximetry to measure oxygen saturation in patients with breathlessness 4
Obtain arterial blood gas measurement on arrival, noting the inspired oxygen concentration, and order chest radiograph as an urgent investigation 5

The British Thoracic Society recommends using a 24% Venturi mask at 2-3 L/min or 28% Venturi mask at 4 L/min to target oxygen saturation of 88-92% in known COPD patients 1
Target oxygen saturation of 88-92% to reduce mortality risk in patients with COPD exacerbation 1, 2, 3
Check arterial blood gases within 60 minutes of starting oxygen therapy and within 60 minutes of any change in inspired oxygen concentration 5
If oxygen saturation remains below 88% despite a 28% Venturi mask, change to nasal cannulae at 2-6 L/min or a simple face mask at 5 L/min, maintaining the target saturation of 88-92% 1

Administer nebulized bronchodilators on arrival and at 4-6 hourly intervals thereafter in patients with COPD exacerbation 5
For patients with COPD and elevated PaCO₂, nebulizers should be driven by compressed air rather than oxygen 5

Consider antibiotics if two or more of the following are present: increased breathlessness, increased sputum volume, or development of purulent sputum in patients with COPD exacerbation 6
Consider oral corticosteroids (usually 30 mg per day for one week) in patients with COPD exacerbation 6
Monitor oxygen saturation continuously until the patient is stable 4
Patients with respiratory rate >30 breaths/min should be triaged as very urgent 1

Lower oxygen concentration if the patient is clinically stable and oxygen saturation is above the target range 7
Most stable convalescent patients will eventually be stepped down to 2 L/min via nasal cannulae prior to cessation of oxygen therapy 7
Stop oxygen therapy once the patient is clinically stable on low-concentration oxygen and oxygen saturation is within the desired range on two consecutive observations 7

Administering high-flow oxygen (>28%) to COPD patients before blood gas results are available, which can worsen hypercapnic respiratory failure 1, 2, 3
Failing to recognize COPD in older smokers with chronic breathlessness 2
Discontinuing oxygen therapy abruptly when respiratory acidosis is detected 2
Inadequate monitoring of oxygen saturation after initiating therapy 4