COPD - Exacerbation Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The management of exacerbation of COPD in adults age 18+ who have an existing diagnosis of COPD

This guidance does not cover:

  • Patients who do not have a current diagnosis of COPD

Assessment

Signs and Symptoms

  • At least 2 of the following changes in the individuals usual symptoms:
  • Increased sputum production
  • Change in colour of sputum
  • Worsening breathlessness

History and Examination

  • Changes in level of consciousness
  • Cyanosis
  • Ability to speak in sentences
  • Heart Rate
  • Respiratory rate, depth and pattern
  • Oxygen Saturation Level
  • Observe for signs of •signs of hypercapnia (CO2 retention) for example flushed skin, hand flapping, full pulse

Differential Diagnoses

  • Clinicians should remain vigilant for the development of pneumonia as the clinical features overlap with those of COPD

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Inability to speak in sentences
  • Respiratory rate >25 per minute
  • Severe breathlessness
  • Worsening hypoxemia and oxygen saturation less than 90%, or 85% in those known to have target saturations of 88-92% require immediate referral and arterial blood gas analysis
  • New or worsening cyanosis
  • Impaired consciousness
  • Signs of hypercapnia (CO2 retention) for example flushed skin, hand flapping, full pulse
  • Worsening peripheral oedema
  • Poor social circumstances

Management

Patient presenting to a Healthcare Professional with acute exacerbation of COPD- Consider red flags

If patient can be self-managed at home

  • Usual Short Acting Bronchodilator 10 puffs via large volume spacer OR
  • Consider nebulised salbutamol (2.5-5mg) as a one off treatment if clinically appropriate
  • Never issue home nebuliser without respiratory specialist / hospital assessment
  • Refer to ADMISSION AVOIDANCE TEAM if nebuliser is being considered
  • Increase frequency of Short Acting Bronchodilator, consider using large volume spacer
  • If significant increase in breathlessness or wheeze START (plain) prednisolone 40mg/day for 5 days
  • If purulent sputum START amoxicillin 500mg tds for 5 days (if penicillin allergy, prescribe Clarithromycin 500mg BD for 5 days or Doxycycline 200mg OD for 1 day and then 100mg OD for 6 days)
  • If patient fails to respond to amoxicillin, send a sputum sample for culture and sensitivity before commencing alternative antibiotic as indicated above
  • If patient fails to respond. Please refer to The Antimicrobial Guidelines for Primary and Community Care Organisations and discuss with microbiologist
  • Advice for patient: If you don't improve in 48 Hrs (2 days) or if you worsen at any time contact your GP or PN
  • Consider face to face or telephone follow up in 2-5 days time

If patient can be can be managed at home with support

  • As above and Contact: Admission Avoidance team on: 01924 543035/541827

If patient cannot be managed at home

  • Treat breathlessness while waiting for the ambulance
  • Short Acting Bronchodilator 10 puffs via large volume spacer OR
  • Consider nebulised salbutamol (2.5-5mg) as a one off treatment
  • Admit

Planned follow up for all patients

  • Early follow-up planned with named health professional in Primary Care within 14 days
  • Assessment by Community Matron/ Respiratory Nurse Specialist/District Nurse/
  • Social Services as appropriate
  • Referral to Pulmonary Rehabilitation
  • Establish on optimal therapy (see COPD Preferred Inhaler Guidelines) as per local guidelines for Management of Stable COPD, written Self-Management Plan and education regarding self-management and when to seek help
  • Never issue home nebuliser without respiratory specialist / hospital assessment

Rescue medication

  • Prednisolone and Antibiotics should no longer be issued routinely to be held at home by patients in primary care as part of self-management. In patients where rescue medication is thought appropriate please discuss support with local Respiratory Specialist Team

Referral

Referral Criteria

  • Red flags
  • if patient is not suitable for the Admission Avoidance refer for admission and ensure planned follow up (see managment) is arranged on discharge
  • if patient is suitable for the Admission Avoidance team (see management) referrals can be made via telephone
  • Wakefield - Referral criteria for Pulmonary Rehabilitation for Patients: (click here to see Wakefield referral pathway)
  • North Kirklees - Referral criteria for pulmonary rehabilitation

Referral Instructions

  • e-Consultation is available for this speciality
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type
  • Referrals to the Admission Avoidance team can be made by ringing: 01924 543035/541827
  • Wakefield - Referrals to Pulmonary Rehabilitation via a completed referral form which should be faxed to:: 01977 668748
  • North Kirklees - Referrals to Pulmonary Rehabilitation via completed referral from which should be faxed to: 01924 512059 or emailed to: melanie.ritson@midyorks.nhs.uk

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Signpost patient to Decision Making aid COPD this can be printed off for the patient

Patient information/Public Health/Self Care

Supporting information

Evidence/ Additional Information

Assurance & Governance

  • This guidance was developed on: 02.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 05.2017
  • Publication Date: 05.2017
  • Review Date: 02.2019
  • Ref No: RS1 – 02.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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