Indications for hospital assessment or admission for exacerbations of COPD
Marked increase in intensity of symptoms, such as sudden development of breathlessness at rest
Severe underlying COPD
Onset of new physical signs(e.g. cyanosis, peripheral oedema)
Failure of exacerbation to respond to initial medical management
Significant comorbidities
Frequent exacerbations
Impaired level of consciousness
Confusion
Diagnostic uncertainties
Older age
Insufficient home support
Who to refer:
For confirmation of new cases of COPD, consider referring for Spirometry only (which includes reversibility to salbutamol) using the ‘Primary Care Spirometry request’ form in Gateway
Reason
Purpose
There is diagnostic uncertainty
Confirm diagnosis and optimise therapy
Suspected severe COPD
Confirm diagnosis and optimise therapy
Onset of cor pulmonale
Confirm diagnosis and optimise therapy
Frequent exacerbations (two or more/year)
Optimise therapy
Rapidly progressive course of disease (a rapid decline in FEV1, progressive dyspnoea, decreased exercise tolerance)
Encourage early intervention
Assessment for oxygen therapy
Optimise therapy and measure blood gases
Assessment for long-term nubuliser therapy
Optimise therapy and exclude inappropriate prescriptions
Assessment for oral coticosteroid therapy
Justify need for long-term treatment or supervise withdrawal
Bullous lung disease
Identify candidates for surgery
Assessment for pulmonary rehabilitation
Identify candidates for pulmonary rehabilitation
Assessment for lung volume reduction surgery
Identify candidates for surgery
Assessment for lung transplantion
Identify candidates for surgery
Dyfunctional breathing
Confirm diagnosis, optimise pharmacotherapy and access other therapies
Aged under 40 years or a family history of alpha-1-antitrypsin deficiency
Identify alpha-1 antitrypsin deficiency, consider therapy and screen family
Uncertain diagnosis
Make a diagnosis
Symptoms disproportionate to lung function deficit
Look for other explanations
Frequent infections
Exclude bronchiectasis
Haemoptysis
Exclude carcinoma of the bronchus
Who not to refer:
See above
See management advice for patients with stable COPD
How to refer:
Use Sci Gateway for referral to these services.
Royal Infirmary of Edinburgh, Respiratory Medicine Clinics, Spirometry only or respiratory OP clinic
Western General Hospital, Edinburgh, Respiratory Medicine Clinics, Spirometry only or respiratory OP clinic
St. Johns Hospital, Howden, Livingston, Respiratory Medicine Clinics
Leith CTC, Respiratory Medicine Clinics, Spirometry only or respiratory OP clinic
Many patients with an exacerbation of COPD can be managed successfully at home. However, there should be a low threshold for emergency admission to hospital for patients with evidence of a severe exacerbation of COPD and for those who do not respond to initial treatment. Decisions about management of a patient with an exacerbation of COPD will vary depending on the patient’s individual circumstances including the severity of their underlying disease, the presence of other medical conditions, and their social situation.
The following algorithm provides guidance for the management of COPD exacerbations in primary care (for use in GP practices and out of hours service).
