Approximately 1.2 million people are living with chronic obstructive pulmonary disease (COPD), which is over 30% more than the previous estimations made by the Department of Health in 2011 (Department of Health, 2011; British Lung Foundation, 2022). COPD is the second most common lung disease in the UK, with asthma being the most prevalent. About 2% of the entire population, along with 4.5% of all people over the age of 40, are living with diagnosed COPD (British Lung Foundation 2022). The number of people diagnosed has increased sharply by 27% over the last decade from 1600, to almost 2000 per 100 000 people in the UK, and many cases may remain undiagnosed (British Lung Foundation, 2022). Currently, the UK is one of the 20 countries with the highest mortality rates for COPD globally, with only Denmark and Hungary having higher mortality rates than the UK in the entirety of Europe.
A person's COPD may be manageable, but the individual is susceptible and vulnerable to infection at any stage. This is known as an exacerbation-an unfortunately common occurrence in persons with COPD, and is often seen by community nurses managing such patients. The National Institute for Health and Care Excellence (NICE, 2016) defines an exacerbation as a sustained worsening of someone's symptoms that is acute in onset and goes beyond the usual variations seen throughout the person's daily life. The main symptoms to look out for are: worsening breathlessness, coughing, increased sputum production and change in the colour of the sputum (NICE 2016).
A person with COPD who requires community nursing input often has oxygen in their home. This may be given in an emergency when someone is experiencing an exacerbation. NICE (2016) states that someone receiving emergency oxygen for an acute exacerbation of their COPD should have their oxygen saturation levels maintained at between 88% and 92%. It is common for someone who has had an acute onset of these symptoms to have their oxygen saturation levels drop considerably. The author has seen an exacerbation where someone's oxygen was at around 60% until this was optimised with oxygen therapy and intravenous antibiotics in the hospital setting.
The reason the oxygen levels drop is due to a worsening of gas exchange in the lungs. However, it is extremely important to be aware that oxygen optimisation must be controlled. If oxygen is increased with the aim of increasing the saturations to levels the body cannot achieve (i.e. above 88-92%) in a person with COPD, the outcomes can be deadly. Uncontrolled oxygen therapy can result in a reduction of depth and frequency in breathing, causing blood carbon dioxide levels to rise and blood pH to fall, known as acidosis (NICE, 2016). It is important to maintain a flow rate through a device, to carefully monitor and aim for the 88-92% saturation levels that the body of the COPD patient is able to cope with.
Echevarria et al (2021) wrote on this subject, noting the target ranges in British and Europe to be 88–92% in an exacerbation, and 94–98% if the carbon dioxide levels are normal. The study assessed the baseline saturation levels of patients during admission and looked at the mortality among these individuals in relation to their oxygen levels. The researchers found that inpatient mortality was at its lowest in people with oxygen saturations between 88%-92%, and that even modest elevations such as those between 93-96% were associated with an increased mortality. This trend was also observed in those with hypercapnia and normocapnia. Echevarria et al (2021) stated that this indicates that the practice of setting different target saturations based on carbon dioxide levels is not justifiable, concluding that all patients with COPD should have target saturations of 88-92%, which in turn can simplify prescribe and improve outcomes. This, therefore, is in line with the current NICE (2016) recommendations.
The British Medical Journal (BMJ, 2022) explored the presentation of an exacerbation in more detail, stating that treatment would involve bronchodilators, systemic corticosteroids and antibiotics. In the community, these would usually be supplied as packs already prescribed and prepared and left in the patient's house. This is to ensure that the patient is started on the treatment when it becomes apparent that they have symptoms of an exacerbation. Therefore, as a community nurse, it is always important to check that stocks of these packs are replenished and available when required, otherwise a patient could deteriorate fast without such intervention on hand in the patient's home.
It is important to also consider that antibiotics should be given for a bacterial infection. This would be noted where there is a change in the volume and colour of the sputum expectorated (BMJ, 2022). The BMJ (2022) note the key diagnostic factors for an infection are: dyspnoea, cough, wheezing, increased sputum purulence and volume, as well as chest pain and tightness, tachypnea, tachycardia and cor pulmonale.
It is important to look at risks for exacerbations in order to take preventative measures to avoid any further deterioration. There are ways to predict exacerbations and personalise care accordingly. Adibi et al (2020) discuss this in their paper relating to the Acute COPD Exacerbation Prediction Tool (ACCEPT) they designed. The researchers state their model is validated, generalisable and can predict the individualised rate and severity of COPD exacerbations. In their study, Adibi et al (2020) pooled data from three trials on COPD patients presenting with frequent exacerbations. The authors developed a mixed-effect model that can predict exacerbations across the period of one year, classifying severe exacerbations as those requiring inpatient hospital care. The predictors for exacerbations were concluded to be: history of exacerbations, age, sex, body-mass index, smoking status, domiciliary oxygen therapy, lung function, symptom burden and current medication use. The tool was then externally validated using the Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE) study (Adibi et al, 2020). The study included a total of 2380 patients, with a mean age of 64.7 years. The mean rate for exacerbations in total was 1.42 events per year, 0.29 events being classified as severe. Using the tool, the predictions were found to match the observed exacerbation rates and external validation showed the tool to be accurate. Therefore, Adibi et al (2020) concluded that their ACCEPT tool can be used in order to personalise the treatment of COPD patients and to help prevent exacerbations.
The authors strongly recommend looking at the NICE (2021) scenario for treatment of an acute exacerbation of COPD, which is summarised here. For someone who does not require hospital admission, the following is recommended when experiencing an exacerbation:
- Increase the dose or frequency of short activing bronchodilators such as Salbutamol-which is already prescribed as medication for this disease and can therefore be advised without GP involvement; supervise the use of a nebulizer or other devices as already prescribed, as treatment should be optimized and the patient may not use this effectively. The nebulizer may be better for someone who is fatigued by their exacerbation and unable to efficiently use the inhaler, and should be used with the prescribed gas and nebules. If corticosteroids are in their pack and are not contraindicated, then the patient may need these. If unsure, ask the district nurse or GP. Usually, prednisolone would be prescribed and given once a day as a 30mg oral dose, for five days, supervised by the community nurses (NICE, 2021).
- The patient may need antibiotics where there are signs of bacterial infection (sputum colour changes and increased volume/thickness of mucus). Usually, provision would be for Amoxicillin 500 mg three times a day for 5 days, or Doxycycline 200 mg on day 1, then 100 mg once daily for 5 days, or Clarithromycin 500 mg twice a day for 5 days (NICE, 2021). If there is no improvement after 2 days, send a sputum sample to be tested. Take observations and check if there is a need for prescribed oxygen-seek advice from a nurse specialist such as a district nurse if you are unsure. Gain specialist advice where symptoms show no improvement despite repeated antibiotic treatment courses, or in the case of antibiotics-resistant bacteria, or where the person cannot take oral medication.
- Some patients will require hospital admission. NICE (2021) advises that someone should be considered for emergency admission if they are severely breathless, unable to cope at home despite support, show deteriorating conditions, have significant comorbidity such as type 1 diabetes or cardiac disease, show rapid onset of symptoms, acute confusion, impaired consciousness, cyanosis, or where there are oxygen saturations of lower than 90%. In the case of these saturations, NICE (2021) advises to give oxygen while awaiting emergency transfer, monitoring response with pulse oximetry, or to give COPD oxygen using a Centuri 24% mask at 2-3L/min, with target saturations as stated above. Emergency admission is also warranted in cases where there is worsening peripheral oedema, new arrhythmia, failure of the infection to respond to the initial treatment, or where the patient already receives long-term oxygen therapy (NICE, 2021). Speak with the team lead about hospital at home schemes, as these are often possible to arrange in some areas.
Overall, it is important to remember how to notice the risks in someone with COPD for developing exacerbations. It is important to know how to identify the start of an exacerbation, what to do when it does, who to speak to and what to prescribe. It is also important to know about the types of support provided in the coming days, and to keep emergency medication stocks replenished in a COPD patient's home. Personalised prevention plans, care and treatment plans are very important for the swift and tailored care that suits the needs of each patient. Exacerbations are common and some are fatal. Identifying where hospital admission is required is essential.