Respiratory CRT Management of acute exacerbations of COPD

Factor	Favours treat at Home	→→→→→→→→	→→→→→→→→	Admit
Previously required intubation /Niv for ex – acerbation	Not needed	Not needed or has an active plan not to be intubated	Previous NIV, but not so unwell that needs it this time	Previous NIV, ITU, high chance will be needed this admission
Know C02 retainer	Not known of known to be normocpnic	Known but recorded PaC02 <7 kPa	PaCO2 7-8 kPa when well	Recorded PaCO2 >8 when well
Already receiving Long Term O2	No	No or SaO2 <3% of usual on usual FiO2	SaO2 >3% worse but >86% on usual O2	<86% on LTOT and/or >5% worse than usual
Breathlessness	Doing all activities	Housebound	Limited to chair	Bed bound
Sputum quantity/colour	White, grey yellow	Yellow	Green purulent, brown, bloody need for CXR	More than an egg cup full of blood/green
Central cyanosis (blue tongue)	Absent	Absent or usually is cyanosed	New, need for ABG	New and very breathless
Worsening peripheral oedema	Absent	Known about	Much worse, refer for CXR, ECG etc.	On its own not a reason to admit
Level of consciousness	Normal	Mild disorientation but has support, CGS 14/15	New Confusion GCS 12/13	Severely impaired GCS <12
General condition	Up and about	Housebound	Chair bound	Bed bound
Significant co-morbidity	None	Controlled	Need assessment e.g. bloods, CXR ECG	Complex interacting medical problems
Tiring?	Good depth of breathing	Laboured but not tired	Laboured at risk of becoming tired.	Very fatigued, great effort to breathe
Level of distress	Minimal	Mild to moderate	Moderate	Severe
Usual Level of activity	Active	Mainly housebound	Chair/Bed bound	Chair/Bed bound
Social circumstances	Good	People present	Some more support could be organised	Appalling
Coping	Coping	Cope with more support	Unlikely to be able to cope in short term	Unable to support in short term
Able to take treatment & react if deteriorates	Yes	Yes	Possibly	NO
Rate of onset of illness	Slow	Slow/chronic	Fast	Fast on chronic
Respiratory rate	10-20	10-25	<10 or >25	>30 or <8
Pulse	60-110	50-110	<50 or 110-120	<50 or >120
BP	Usual or >100/60	Usual or >100/60	Anything else	<90/55 or >210/120
Oxygen saturation if not already on O2	>91% on air (i.e. 92 or more)	>89% on air or within 3% of usual	86-90% on air and more than 3% worse	<86% or 5% worse than usual on usual FiO2
Signs of pneumonia (bronchial breathing)	Reasonably well & responding to antibiotics	Reasonably well and responding to antibiotics	If unsure for CXR etc.	2 of: Confusion, RR>30, age >65, diastolic BP <60
Escalation Plan (EP)	Hospitalisation to be avoided if possible	EP –acute hospital care not appropriate	EP –should be assessed only to exclude others treatable conditions	EP –shows plan for hospitalisation

 

Adapted from: http://www.nice.org.uk/nicemedia/pdf/CG012_niceguideline.pdf,BTS Guidelines. Thorax (2007); 62:200-210

All factors are important. It is the whole picture that determines patient management.

Decision to admit will be at the discretion of the senior physiotherapist in consultation with the primary healthcare provider.