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					GP and Residential Aged Care Kit
                        Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease

Respiratory:
Chronic Obstructive Pulmonary Disease
This Clinical Information Sheet (CIS) has been developed to assist RACF staff, medical
practitioners and relevant professionals (pharmacists, allied health clinicians) involved in the
management of residential aged care patients with Chronic Obstructive Pulmonary Disease
(COPD). It addresses issues that may occur in RACF, particularly optimising function of residents
with a pre-existing diagnosis of COPD, management of acute exacerbations, and end of life care.

It covers:
 About Chronic Obstructive Pulmonary Disease (COPD);
 Assessment;
 Management;
 Maintenance Medication;
 Non-pharmacological Strategies;
 Acute Exacerbations;
 End stage COPD; and
 Sources of Information.

Reference cards:      Modified Medical Research Council Dyspnoea Scale
                      Modified Borg Dyspnoea Scale
                      Visual Analog Dyspnoea Scale

This Clinical Information Sheet is a guide only. It should be used with consideration to:
 Resident’s preferences, existing medical care plans, and Advance Care Plan;
 Health professional’s role, knowledge, preferences and professional experience;
 Policies and resources available within the RACF;
 Requirements of local professional registration and regulatory bodies; and
 Relevant local legislation.


About Chronic Obstructive Pulmonary Disease (COPD)
Chronic Obstructive Pulmonary Disease is a significant health problem in Australia, ranked as the
third leading cause of death [1]. COPD is responsible for significantly more morbidity and
mortality than other airway disease in adults aged over 60 years [2]. The disease affects 52 million
adults worldwide. The increasing death rate from COPD is a significant burden on western health
care resources. For older adults requiring hospitalisation, the mortality rate is 11%, with a six
month mortality rate of 33% and one year mortality rate of 43% [3]. In Australia COPD caused
over 5000 deaths in 2003 [4].

Chronic Obstructive Pulmonary Disease is a general term used to describe respiratory tract
conditions that have the same disease process. The term broadly covers the diagnoses of
emphysema, chronic bronchitis and some chronic forms of asthma. The major clinical feature
common to diseases classified as COPD is the trapping of air in the lungs [5].

The disease generally has a slow progression and is characterised by irreversible damage and
gradually worsening respiratory function due to chronic inflammation and obstruction of the
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                         Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease
airways [2, 3, 6-9]. The progression of COPD leads to decreased quality of life, decreased ability to
perform activities of daily living (ADLs) and, in the end stages, significant risk of respiratory
failure [6, 7].

Assessment
The aim of assessment is to determine the diagnosis and severity of Chronic Obstructive Pulmonary
Disease (COPD).

The diagnosis is usually made by the GP based on clinical assessment, chest X-ray and spirometry.
Some residents may be referred to a respiratory specialist for further pulmonary function tests and
advice [7, 9]. Other investigations to aid management include pulse oximetry, arterial blood gases
and FBE.

Diagnosis of COPD rests on the demonstration of airflow limitation, which is not fully reversible. If
airflow limitation is fully or substantially reversible, the patient should be treated as for asthma [7,
9]. (See the Clinical Information Sheet on Respiratory: Asthma.)

Residents with COPD should be reassessed regularly, at least annually for mild-moderate COPD
and 6 monthly for severe COPD.

Signs and symptoms
Signs and symptoms of COPD include [2, 6-8, 10]:
- Dyspnoea with or without accompanying wheeze;
- Shortness of breath;
- Cough with or without sputum production;
- Decreased endurance;
- Hypoxaemia;
- Pursed-lips breathing;
- Hypercapnia (high levels of CO2);
- Decreased FEV1 (forced expiratory volume in 1 sec); and
- Respiratory acidosis.

In order to make an early diagnosis, it is recommended that residents who are smokers or ex-
smokers be assessed for COPD if they suffer episodic shortness of breath, have a persistent cough,
or experience frequent respiratory tract infections [4, 6-11].

COPD and asthma have similar presentations, and they commonly occur together. Table One
represents differences in symptoms.

Table One: Symptoms of COPD and Asthma [7]

 Symptoms                                              COPD                          Asthma
 Smoker or ex-smoker                                   Nearly all                    Possibly
 Symptoms under age 35                                 Rare                          Common
 Chronic productive cough                              Common                        Uncommon
 Breathlessness                                        Persistent and progressive    Variable
 Night-time waking with breathlessness                 Uncommon                      Common
 and/or wheeze
 Diurnal or day-to-day variability in                  Uncommon                      Common

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                         Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease
 symptoms

Investigations

Spirometry
Diagnosis of COPD is made by measurement of airflow obstruction using spirometry [5, 6, 8, 9].
Spirometry measures lung function, as the volume of air expired in 1 second (FEV1) and the total
volume of air expired as fast as possible (FVC). Results are compared to the resident’s previous
values, or to predicted values for his or her age range [12]. Following a baseline spirometry
reading, spirometry is usually conducted pre and post administration of a bronchodilator to detect
partial reversible airway obstruction such as asthma.

COPD is diagnosed when FEV1 is <80% of the predicted value for a person’s age, and the
FEV1:FVC ratio is less than 70% [2, 4, 6-8, 10, 13]. Severity of COPD is classified as moderate at
50-80% predicted FEV1, severe at 30-49% and very severe at <30% predicted FEV1 [7-10]. Asthma
is differentiated from COPD by the response of at least 12% improvement in the patient’s FEV1
within 15 minutes of administration of a short-acting beta2-agonist [6, 8, 9].
Chest X-ray
A chest X-ray may be normal or show signs of hyperinflation, flattened diaphragm, or large, dilated
airspaces that bulge from beneath the pleura known as bullae [8]. Chest X-ray is recommended to
check for differential diagnoses such as lung cancer [9], and those described in Table Two. In older
adults, findings on chest X-ray change the diagnosis and management plan in approximately 16-
21% of cases [3, 8, 10].
Pulse oximetry
Pulse oximetry is used to monitor oxygen saturation in residents with COPD, particularly during
oxygen therapy to titrate oxygen levels to maximise oxygen saturation, whilst minimising the risk
of hypercapnia. Residents with oxygen saturations of less than 80% on air require arterial blood
gases and management in an acute care facility is required [8].
Arterial blood gases
For patients with severe COPD (FEV1 <40% predicted) or signs and symptoms of respiratory or
heart failure arterial blood gas measurement may be performed by arterial puncture [7, 8, 10]. This
usually requires transfer to an acute care facility with the appropriate equipment. The Advance Care
Plan and goals of care should be considered before initiating aggressive assessment and
management.

Differential diagnosis
Table Two shows features of COPD and differential diagnoses. Asthma is the major differential
diagnosis. Diagnosis of COPD rests on the demonstration of airflow limitation, which is not fully
reversible. If airflow limitation is fully or substantially reversible, the patient should be treated as
for asthma [7, 9]. (See the Clinical Information Sheet Respiratory: Asthma.) Where there is doubt,
a trial course of corticosteroids may be initiated to determine response (more rapid in asthma) [4, 6,
9, 13].




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Table Two: Features of COPD and differential diagnoses [7, 8, 10]
                Onset and    History        Signs & symptoms              Investigations      Clinical
                Progression                                                                   outcome

COPD             Onset in         Long          Dyspnoea during           Pulmonary           Largely
                 mid-life.        smoking       exercise.                 function tests      irreversible.
                                  history.      Little daily variation    indicate
                 Progression                    in signs and              irreversible
                 usually                        symptoms.                 airflow
                 slow.                          Fine crackles and         restrictions
                                                wheeze on                 Chest X-ray
                                                auscultation.             may be normal
                                                                          or show
                                                                          hyperinflation
                                                                          flattened
                                                                          diaphragm, or
                                                                          bullae.

Asthma           Onset early       Family       Fine crackles and         Pulmonary           Largely
                 in life (often   history of    wheeze on                 function tests      reversible.
                 childhood).      Allergies.    auscultation.             indicate
                                                Daily variation in        reversible
                 Daily                          signs/symptoms.           airflow
                 variations in                  Often                     restrictions.
                 progression.                   signs/symptoms
                                                present at night or
                                                early morning.
                                                Often have
                                                accompanying
                                                allergies, rhinitis and
                                                or eczema.

Cardiac          Mid-late life                  Fine basal crackles       Chest X-ray         Largely
Failure          onset with                     on auscultation.          shows dilated       reversible.
                 varied                         Little daily variation    heart,
                 progression.                   in signs and              pulmonary
                                                symptoms.                 oedema.
                                                                          Pulmonary
                                                                          function tests
                                                                          indicate volume
                                                                          restriction
                                                                          rather than
                                                                          airflow
                                                                          limitation.




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                       Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease
                 Onset and   History            Signs & symptoms         Investigations       Clinical
                 Progression                                                                  outcome

Bronchiectasis                                  Large volumes of         Coarse crackles
                                                purulent sputum often    on auscultation.
                                                with associated          Chest x-ray
                                                respiratory infection.   bronchial
                                                Little daily variation   dilation and
                                                in signs and             wall thickening.
                                                symptoms.

Tuberculosis     Onset at all    Local          Cough, often             Chest X-ray          Reversible.
                 ages.           prevalence     associated with blood    shows lung
                                 of             droplets.                infiltrate or
                 Progression     tuberculosis   Fatigue.                 nodular lesions.
                 varied but      or travel to   Night sweats.            Microbiology
                 usually         an area                                 confirms
                 slow.           where TB is                             diagnosis.
                                 prevalent.

Obliterative     Onset in        Pulmonary      Large volumes of         Coarse crackles      Largely
Bronchiolitis    younger         surgery.       purulent sputum often    on auscultation.     irreversible.
                 ages.                          with associated          Chest X-ray
                                 History of     respiratory infection.   bronchial
                                 rheumatoid     Little daily variation   dilation and
                 Progression
                                 arthritis is   in signs and             wall thickening.
                 usually
                                 common.        symptoms.
                 slow.


COPD and depression
The long-term debilitating effects of COPD and anxiety related to chronic breathlessness
significantly increase the risk of depression [9]. Residents diagnosed with COPD who have
oxygen saturations of less than 92%, severe dyspnoea, and/or have been admitted to hospital for
management of an acute exacerbation should routinely be screened for anxiety and depression [7].

Classifying severity of COPD
Generally FEV1 is used as the primary indicator of severity and as a guide for ongoing management
of COPD [7-10]. Table Three outlines the severity classifications used for COPD.

Table Three: COPD severity classifications [7-10]
 Severity           FEV1                          Typical signs/symptoms

 Mild                  80% predicted or greater       Little or no dyspnoea.
                                                      Cough with or without sputum.

 Moderate              50–80% predicted               Breathlessness.
                                                      Wheeze with moderate exertion.
                                                      Cough with or without sputum.
                                                      Variable abnormal signs.
                                                      Reduction in breath sounds.
                                                      Possible hypoxemia.

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 Severe                 30–49% predicted                Dyspnoea with any exertion.
                                                        Prominent cough and wheeze.
                                                        Cyanosis.
                                                        Peripheral oedema.
                                                        Hypoxemia and hypercapnia are common.

 Very severe            < 30% predicted                 Dyspnoea at rest.
                                                        Prominent cough and wheeze.
                                                        Cyanosis, possibly centrally.
                                                        Peripheral oedema.
                                                        Hypoxemia and hypercapnia are common.

Severity or level of stable COPD can also be assessed using the Modified Medical Research
Council (MRC) Dyspnoea Scale provided in the Reference Cards. Although this scale is not the
most appropriate to assess responses to interventions, the modified MRC Dyspnoea Scale provides
a useful baseline assessment of the resident and a change of one level or more on the scale is
clinically significant [14].

Management
Goals in managing a resident with COPD are to [2]]:
 Improve quality of life;
 Increase physical endurance;
 Maintain optimal ventilation;
 Reduce anxiety;
 Manage co morbidities;
 Decrease unnecessary hospitalisations and use of medical resources; and
 Maintain comfort in the end stages through respiratory failure.

Residents with COPD should have a management plan developed by the general practitioner with
residential care staff, the resident and/or his or her representative, and be reviewed at least annually
[7, 8].

The management plan is based on clinical assessment including [5-9, 13]:
 Smoking and nutritional status
 Adequacy of symptom control – breathlessness, exercise tolerance, exacerbation frequency
 Effects of medication
 Inhaler technique
 Presence of complications – cor pulmonale
 Co morbidities - cardiac failure, depression, anxiety,
 Measurements of FEV1 and FVC, BMI, oxygen saturation
 Need for long term oxygen therapy;
 Need for referral (specialist, physiotherapy, occupational therapy, dietitian), and
 Resident’s preferences for care.




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                        Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease
The following information should be documented in the resident’s management plan to [[4, 6, 9, 11,
13]:
 Usual severity of COPD and baseline signs and symptoms;
 Frequency and presenting pattern of exacerbations;
 Non-pharmacological strategies;
 Medication for maintenance therapy and exacerbations;
 How to identify and respond to exacerbations, and
 Advance Care Plan.

Medication
Medication reduces signs and symptoms and minimises exacerbations, but they do not reverse
existing damage or prevent the eventual decrease in lung function [4, 10].

Medication prescribed for COPD is generally taken by inhalation using an appropriate medication
delivery device e.g. puffer, nebuliser. Residents with poor inhaler technique can use a spacer with a
metered dose inhaler to improve lung deposition. Avoid using a nebuliser for stable COPD unless it
has been shown to be better for the individual [9, 15].

Further information about prescribing medications in a form most appropriate to the resident, and
techniques for using various delivery devices, is outlined in the Clinical Information Sheet
Respiratory: Inhalation Medication Delivery Devices.

Long-term medication generally includes all, or a combination of [6-8, 10, 16]:
 Short-acting inhaled bronchodilators (beta2 agonists, anticholinergics);
 Long-acting inhaled bronchodilators;
 Inhaled corticosteroids;
 Long-term oxygen therapy;
 Immunisation (influenza and pneumococcal).

Prophylactic antibiotic therapy has not been shown to reduce acute exacerbations or decrease signs
and symptoms in residents with stable COPD and therefore is not recommended in long term
management [7].

Antitussives and Mucolytics
Antitussives (cough suppressants) are generally not recommended in the management of COPD, as
cough has a protective effect on the airways [8, 10].

Use of mucolytic agents (products that break down mucous), such as bromhexine or acetylcysteine,
have been shown to slightly reduce the number and duration of acute exacerbations for some
residents who have frequent exacerbations [9, 15].

Short-acting Bronchodilators
Short-acting Bronchodilators are the first-line therapy for residents with COPD. Either short-acting
beta2-agonists e.g. Salbutamol, Terbutaline or short-acting anticholinergics e.g. Ipratropium may be
used [7-9, 13]. Medications may initially be prescribed on an as-needed basis, increased to regular
timed doses as the resident’s symptoms progress [13].

Ipratropium bromide is the inhaled reliever medication used most often in COPD, particularly for
older adults [12, 17, 18]. Due to fewer systemic side effects this medication is recommended as the
reliever medication of choice for older adults with concurrent cardiovascular disease who are taking
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beta-adrenergic blocking agents [19]. Ipratropium is as effective as inhaled beta2-antagonists in
maintenance therapy of COPD.

Long-acting Bronchodilators
Long-acting inhaled bronchodilators are used in residents for whom the improvement in lung
function is insufficient despite the use of short-acting bronchodilators, or those who have at least 2
exacerbations per year. Either long-acting beta2-agonists e.g. Formoterol, Salmeterol or long-acting
anticholinergics e.g.Tiotropium may be prescribed [4, 7, 9, 13]. Because Tiotropium has a longer
duration of action than Ipratropium it may be administered only once per day. Its efficacy is slightly
better than Ipratropium in maintenance therapy of COPD. Anticholinergic adverse effects, e.g. dry
mouth, occur more often than with the short-acting ipratropium [4, 13, 20].

Inhaled corticosteroids
Regular systemic corticosteroids e.g. prednisolone have been shown to have minimal effect on lung
function in most residents with COPD [9, 10]. However, inhaled corticosteroids - preventive
medications that help control inflammation in the airways e.g. fluticasone, budesonide,
beclomethasone are useful in severe and very severe COPD, (FEV1 < 50% predicted), [4, 6-10, 13,
16] or for residents experiencing more than two acute exacerbations in a year [7].

The most common side effects from inhaled corticosteroids are oral candidiasis and throat
hoarseness. Residents should be encouraged to use a spacer for administering corticosteroids and to
rinse the mouth well after each dose [13, 19, 21-24].

Residents on larger doses of inhaled corticosteroids or those who take systemic corticosteroids, are
at risk of osteoporosis as these medications cause a decrease in bone mineralisation. The lowest
possible dose to achieve a therapeutic effect should be used. Calcium and vitamin D supplements
and regular screening for osteoporosis (annually for residents on doses equivalent to greater than
5mg prednisolone daily) are recommended for individuals at risk [5, 9, 19, 21]. A falls risk
assessment should be conducted for residents at risk of osteoporosis to minimise the risk of injury
and fractures.

Further information on assessment and management of resident falls is provided in the Clinical
Information Sheet Resident Falls.

Theophylline
Theophylline has an anti-inflammatory effect as well as a being a bronchodilator. Toxicity is
common as it has a very narrow therapeutic range and many drug interactions. Therefore it is
generally recommended only for severe respiratory disease and is not recommended for use in older
adults unless absolutely necessary [19, 21, 23]. Slow-release preparations of Theophylline may be
considered for residents who do not respond to short-acting and/or long-acting bronchodilators, or
for those who are unable to take inhaled medications [13]. Dosage is based on therapeutic response
and trough plasma concentrations [5, 9, 19, 21].

Oxygen Therapy
-   Nocturnal hypoxaemia (oxygen saturation less than 90% for more than 30% of time);
-   Peripheral oedema;
-   Pulmonary hypertension ;
-   Cyanosis, and/or
-   Severe airflow obstruction (FEV1 <30% of predicted value).


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                        Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease
Because oxygen therapy may cause respiratory depression from hypercapnia (high level of carbon
dioxide in the blood), residents with COPD should be carefully assessed before LTOT is initiated
[7]. The goal of oxygen therapy should be to maintain oxygen concentration levels at
approximately 90% when the resident is at rest. This saturation level maximises oxygen supply
whilst minimising the risk of worsening hypercapnia [3, 6]. Oxygen should be administered for at
least 15 hours per day, preferably up to 20 hours per day [7, 9].

Further information on oxygen delivery can be found in the Clinical Information Sheet Respiratory:
Inhalation Medication Delivery Devices.

Non-pharmacological Strategies
Management strategies to improve the resident’s quality of life include resident and family
education, relaxation techniques, cognitive behavioural therapy, counselling and antidepressant
medication [7, 9].

Smoking cessation
Smoking is one of the primary causes of COPD and contributes to both disease progression and
increase in exacerbations. Health care workers should encourage and promote the resident to cease
smoking as this is one of the few unequivocally effective interventions, even in late stage disease [4,
6, 7, 9, 11] . Smoking cessation can reduce the frequency of acute exacerbations by up to one third,
even in long term smokers [6]. Comprehensive information about smoking cessation programs,
counselling and support groups for those wishing to stop can be obtained from organisations such as
Quit Victoria (see contact information below) and it is highly recommended that the GP refer
residents who smoke to support services.

Immunisation
Patients with COPD are at increased risk of invasive pneumococcal infection. It is recommended
that elderly people with respiratory disease be immunised against pneumonia and influenza [6-9,
19, 21, 23, 24]. Influenza vaccination halves the risk of exacerbations, hospitalisation and death
from respiratory disease and all causes [7, 9].

Nutrition
Maintaining an acceptable body mass index (BMI) contributes to improved lung function,
decreased incidence of respiratory infection and increased life expectancy [25]. Nutritional intake
may be effected by physical activity level, medications, dyspnoea and concurrent diagnoses such as
depression [26].

Nutritional interventions recommended for residents with COPD include [7, 11, 25, 26]:
- Nutritional screening as part of the diagnostic process;
- Referral to a dietician for those residents who have a BMI outside the recommended range of
   20-25 or who have a serum albumin less than 3.5g/dl;
- A diet consisting of a higher fat intake, as this is associated with decreased production of carbon
   dioxide, and
- Maintenance of adequate hydration, as this contributes to thinning of pulmonary secretions.




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                        Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease
Residents with body weight less than 90% of their ideal weight have a higher risk of mortality and
morbidity. Nutritional strategies recommended for underweight residents with COPD include [25,
26]:
- Small frequent meals;
- Appropriate enteral or parenteral nutritional supplements as recommended by a dietician, and
- Medication review, e.g. consider alternate therapies where medication causes anorexia and/or
    nausea.

Nutritional strategies for overweight or obese residents include [26]:
- Medication review, e.g. consider alternate therapies if medication causes increased appetite, and
- Referral to a dietician for a weight loss regime that maintains an appropriate vitamin, protein
   and fat intake.

Physiotherapy
Regular exercise programs can reduce symptoms of dyspnea, anxiety and depression; and increase
exercise capacity and quality of life [8, 9, 14]. Physiotherapy interventions that are beneficial for
residents with COPD include:
- Regular assessment of ability to perform activities of daily living (ADLs) [7, 14];
- Breathing exercises and pulmonary muscle training [2, 11, 14];
- Secretion-clearing strategies [2, 7, 11, 14]; and
- Energy conserving techniques [11, 14].

The Australian Lung Foundation and the Australian Physiotherapy Association have developed the
Pulmonary Rehabilitation Kit, available at the website
http://www.pulmonaryrehab.com.au/welcome.asp This toolkit has been developed to help health
professionals establish evidence-based pulmonary rehabilitation programs throughout Australia
[14].

Relaxation
Relaxation techniques are effective to reduce fear and anxiety during an exacerbation, however,
there is no evidence that they improve respiratory function [11, 14].

Acute Exacerbations
An acute exacerbation is an episode of worsening signs and symptoms, often with accompanying
respiratory tract infection. A person diagnosed with COPD has on average 2-3 acute episodes
annually, or more often if he or she remains an active smoker [3].

Early identification and prompt treatment of an exacerbation can reduce severity, prevent
complications such as respiratory infection, and reduce hospital admissions [9, 11].

Residents diagnosed with COPD who report worsening dyspnoea, should be thoroughly assessed to
determine severity, and monitored for respiratory failure [9, 11]. Assess increased severity of
symptoms, cyanosis and peripheral oedema, change in mental state and ADLs, and exacerbation of
co morbidities [9, 11].

Treatment is aimed at reducing airflow limitation and inflammation, sputum production and
purulence, hypoxia and acidosis. The action plan for acute exacerbation may include
commencement of bronchodilators, antibiotics, systemic steroids and/or supplemental oxygen while
awaiting medical review [9, 11]. The decision to treat at the RACF, or transfer to hospital for acute
care, will be based on assessment and the resident’s preference.
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                        Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease
Assessment
Commonly reported symptoms are worsening breathless, cough, increased sputum, change in
sputum colour, and reduced ability to perform daily activities. Assess for [3, 8, 9, 11]:
- Worsening dyspnoea and/or chest tightness;
- New or worsening cyanosis or peripheral oedema;
- Altered mental state;
- Fatigue or inability to perform daily activities;
- Increased sputum production or purulent sputum;
- Fever;
- Increased respiratory rate (>25 breaths/min);
- Increased heart rate (>110 beats/min), and
- Worsening hypoxaemia and hypercapnia.
Severity of dyspnoea
The experience of dyspnoea is subjective. Evidence suggests that either a visual analog scale or
numeric scale are most effective in assessing the severity of a resident’s dyspnoea during an acute
exacerbation. These tools can also be used to determine the resident’s response to therapy [11, 27].
The Borg Scale – a numeric scale that assesses severity of acute dyspnoea, and a Visual Analog
Dyspnoea Scale are provided in the Reference Cards. Both scales are reliable indicators of severity
of dyspnoea, however, the visual analog scale is more sensitive to changes in the resident’s
experience of dyspnoea [27].
Pulse oximetry
Level One evidence supports pulse oximetry to monitor oxygen saturation levels in residents with
COPD, particularly during oxygen therapy to maintain oxygen saturations levels at 90-92%. This
saturation level maximises oxygen supply whilst minimising the risk of worsening hypercapnia [3,
6, 7]. Residents with oxygen saturations of less than 80% on air require arterial blood gases and
management in an acute care facility [8].
Arterial blood gases
During an exacerbation of COPD, blood gas measures can monitor risk of respiratory failure and/or
if mechanical ventilation is required [1, 3, 6, 7, 10, 11]. Residents will generally require transfer to
an acute care facility to have arterial blood gases performed, and those with a pH is less than 7.32
require ongoing management in an acute care facility due to the high risk of acute respiratory failure
[8]. The decision to pursue this level of assessment and intervention, therefore, should be discussed
with the resident and his or her representatives. See information on End-Stage COPD below.

Medication
It is recommended that the documented action plan for an acute exacerbation, include PRN
medication orders and a supply of emergency medications [7, 13].

An acute exacerbation of COPD is generally managed with [1-3, 10, 11, 13]:
- Increase in dose and frequency of inhaled bronchodilators;
- Systemic corticosteroids;
- Oxygen therapy, and/or
- Antibiotics for concurrent infection.




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Bronchodilators
Bronchodilators can increase airflow by 15-29% within 2 hours. Although administration via a
metered dose inhaler with spacer is as effective as use of a nebuliser, the latter may be easier for the
resident to use during an acute exacerbation [3, 8, 9].

Salbutamol, a short-acting bronchodilator, is the preferred medication unless contraindicated, in an
acute exacerbation, as its effect is rapid. Inhaled salbutamol can be administered in continual serial
doses until the resident’s symptoms are relieved. If the resident develops side effects e.g.
tachycardia and/or tremor, ipratropium bromide may be added to the resident’s medication regime
to allow for use of lower doses of salbutamol [1, 7, 8, 10, 16].


                             Commence with continuous salbutamol.
             Decrease to intermittent salbutamol when the resident’s signs improve.
         Add ipratropium if no response, or to decrease use of salbutamol [1, 7, 8, 10, 16].


Corticosteroids
Systemic corticosteroids reduce severity and shorten recovery time. They are generally prescribed
for 7-14 days in the event of an acute exacerbation, especially when symptoms interfere with daily
activities [1, 3, 4, 7-9, 13]. If the resident is on a regular corticosteroid regime, the dose may be
increased. Unless the resident is on a regular dose of corticosteroid, tapering the dose is not
required [1].


                        Prednisolone 30-50mg daily for 5-14 days [1, 3, 7, 8].


Oxygen Therapy
Oxygen therapy should be used with care during an acute COPD exacerbation due to the risk of
hypercapnia. The use of pulse oximetry to measure oxygen saturations during oxygen therapy,
therefore, is essential.

Residents with an oxygen saturation level of 80-90% on air should receive oxygen therapy. The
rate should be titrated to maintain oxygen saturation levels at 90-92%. This saturation level
maximises oxygen supply, whilst minimising the risk of worsening hypercapnia [3, 6, 7].

Residents with an oxygen saturation of less than 80% on air should have arterial blood gases
performed [8].

Details on oxygen delivery are provided in the Clinical Information Sheet Respiratory: Inhalation
Medication Delivery Devices.
Antibiotics
Bacterial infection contributes to the severity of an exacerbation of COPD. Broad spectrum oral
antibiotics, e.g. amoxycillin or doxycycline should be prescribed for 5-10 days in the presence of
purulent sputum with increased sputum volume and/or increased dyspnea [1, 3, 4, 8, 13]. A
macrolide antibiotic, e.g. erythromycin, roxithromycin, cephalosporin or amoxycillin plus
clavulanic acid, may be prescribed if there is no response to first line antibiotic therapy, only if
Haemophilus influenzae has been excluded [13]. If pneumonia is suspected, investigate and treat as
for community acquired pneumonia (see Clinical Information Sheet Respiratory: Pneumonia).


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                        Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease
Procedure for Managing Acute Exacerbation of COPD
   1. Reassure the resident and remain calm. Remain with the resident and alert assistance [11].
   2. Assess the resident’s respiratory status including [11]:
        level to which resident is currently experiencing dyspnoea;
        the resident’s usual level of dyspnoea;
        vital signs;
        pulse oximetry;
        movement of chest wall and use of accessory muscles ;
        ability to complete a verbal sentence;
        presence of cough ;
        presence and characteristics of sputum;
        chest auscultation;
        presence of peripheral oedema.
   3. Administer inhaled bronchodilators [3, 11] according to the resident’s medication orders. If
       the resident has no medication orders contact the resident’s GP immediately.
   4. Administer oxygen therapy [3, 6, 7, 11]. Do pulse oximetry and adjust the oxygen flow
       accordingly to maintain oxygen saturations levels at 90-92%. This saturation level
       maximises oxygen supply whilst minimising the risk of worsening hypercapnia [3, 6, 7].
   5. Administer systemic corticosteroids [3, 11] according to the resident’s medication orders. If
       the resident has no medication orders contact the resident’s GP to perform an assessment of
       the resident. Corticosteroids are usually administered for 5-10 days [3].
   6. Monitor the resident’s progress every 15 minutes until the resident’s condition is stable.
   7. If the resident is experiencing pain or discomfort administer analgesia as prescribed [11].
   8. Consult the resident’s Advance Care Plan before calling emergency ambulance services.
   9. Document the episode in the resident’s progress notes according to the facility policy.
       Inform the resident’s GP immediately to request a review of the resident’s condition. Inform
       other care workers according to facility policy, and the resident’s representative according to
       their personal preferences.
   10. Maintain the resident’s ongoing medication regime as prescribed. If the exacerbation is
       accompanied by respiratory tract infection the resident should commence oral antibiotics[3].

Transfer to acute care
Indications for transfer of a resident experiencing an exacerbation of COPD to an acute care facility
include [8]:
- Rapid increase in severity of symptoms;
- A history of severe exacerbations requiring mechanical ventilation;
- Co-morbidities that increase risk of death, e.g. pneumonia, cardiac failure;
- Failure to respond to treatment;
- Increase in dyspnoea and/or hypoxia despite oxygen therapy;
- Decrease in alertness, and/or decrease in ability to perform basic ADLs due to dyspnoea
- Measure arterial blood gases (check for hypercapnia or Ph of less than 7.32), and
- New signs, especially cyanosis or peripheral oedema.

Before arranging for transfer to an acute care facility, refer to the resident’s Advance Care Plan and
consult with their GP and relatives/representatives [28].

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                        Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease
End stage COPD
It is important for the general practitioner to provide education and discuss preferences for End-of-
Life care with the resident and/or his or her representatives. Discussions should include the level of
intervention the resident prefers, and whether or not the resident wishes to be admitted to an acute
care facility for management during an acute exacerbation [8, 11, 28].

The major decision to be made is the level of medical intervention they desire when they are no
longer able to breathe on their own. Appropriate education and support should be provided to assist
the resident in deciding whether s/he wishes:
 To be admitted to intensive care and receive intubation and mechanical ventilation; or
 To receive palliative care within the RACF [28].

Advance Care Plans should be regularly reviewed, particularly where the resident experiences
frequent exacerbations. The Clinical Information Sheet on Advance Care Planning provides more
information.

The likely outcome of palliative care rather than mechanical ventilation is eventual unconsciousness
and a quick death [28]. The Clinical Information Sheet on End-of-Life Care provides more
information about palliative care in COPD and other chronic diseases.

Sources of Information

Where to go for more information

Quit Victoria
Quit Victoria provides support and information for people wishing to quit smoking. There are a
variety of free resources available including a Quit pack with educational material, Quit courses
operating in the community and telephone counselling. Support groups such as Quit Victoria
provide motivation and encouragement, and all smokers should be encouraged to seek assistance in
cessation.
Quitline: 137848
Website: http://www.quit.org.au/
The Australian Lung Foundation
The Australian Lung Foundation provides information, support and counselling for people
diagnosed with COPD, their families and their carers. The Foundation is involved in the
development and review of national COPD guidelines and provide numerous tools relating to the
assessment and management of COPD on its website at
http://www.lungnet.com.au/home/contact.html
Contact: Mon-Fri 9am-5pm for all enquiries: 1800 654 301 (within Australia)
LungNet
LungNet is a co-ordinating network of support groups for COPD and other respiratory diseases.
The organisation, established by The Australian Lung Foundation, connects those requiring support
with the most appropriate local services. LungNet also provide a quarterly newsletter.
Contact during business hours: 1800 654 301




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                             Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease

Further reading
In addition to the references, the following articles are recommended:

            The Australian Lung Foundation and Thoracic Society of Australia and New Zealand’s
             COPD-X website at http://www.copdx.org.au/ provides a comprehensive resource for
             information about COPD including a variety of proforma management plans and
             checklists.
            An online pulmonary rehabilitation toolkit, an initiative of The Australian Lung
             Foundation and the Australian Physiotherapy Association, is available at the website
             http://www.pulmonaryrehab.com.au This toolkit has been developed to help health
             professionals establish evidence-based pulmonary rehabilitation programs throughout
             Australia.
            LungNet Quarterly newsletter – available by registering your interest at the LungNet
             website - http://www.lungnet.org.au/pat_support/whats_lungnet-pat_support.html

References
1. Harvey, P., Murphy, M., Dornom, D., Berlowitz, D., Lim, W., Jackson, B., Implementing evidence based guidelines:
         inpatient management of Chronic Obstructive Pulmonary Disease. International Medicine Journal, 2005. 35(3):
         p. 151-.
2. Karavatas, S., The Integration of the Guide to Phyiscal Therapy Practice in the Management of the Geriatric Patient
         with Chronic Obstructive Pulmonary Disease. Topics in Geriatric Rehabilitation, 2005. 21(2): p. 127-132.
3. Stoller, J., Acute Eaxacerbations of Chronic Obstructive Pulmonary Disease. The New England Jounrla of Medicine,
         2002. 346(13): p. 988-994.
4. McKenzie, D. et al, Managing COPD and preventing progression. National Prescibing Service News, 2006. 45.
5. eTG, Therapeutic Guidelines: COPD, in http://www.tg.com.au (accessed April 2006), eTG. 2005
6. Guidelines and Protocols Advisory Committee, Chronic Obstructive Pulmonary Disease (including patient guide).
         2005, British Columbia Medical Association, (BCMA)
British Columbia Health Services, (BCHS): British Columbia.
7. National Institute for Clinical Excellence, (NICE), Management of chronic obstructive pulmonary disease in adults in
         primary and secondary care. 2004, National Institute for Clinical Excellence, (NICE): London. p. 54.
8. Institute for Clinical Systems Improvement, (ICSI), Chronic obstructive pulmonary disease. 2005, Institute for Clinical
         Systems Improvement (ICSI): Bloomington (MN). p. 66.
9. Australian Lung Foundation, (ALF),Thoracic Society of Australia and New Zealand, (TSANZ), The COPD-X Plan:
         Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2006.
         2006, Australian Lung Foundation, (ALF). p. 66.
10. Global Initiative for Chronic Obstructive Lung Disease, (GOLD) , World Health Organization, (WHO), National Heart,
         Lung and Blood Institute, (NHLBI), Global strategy for the diagnosis, management, and prevention of chronic
         obstructive pulmonary disease. 2005, Global Initiative for Chronic Obstructive Lung
Disease, World Health Organization, National Heart, Lung and Blood Institute: Bethesda (MD). p. 115.
11. Registered Nurses Association of Ontario, (RNAO), Nursing care of dyspnea: the 6th vital sign in individuals with
         chronic obstructive pulmonary disease (COPD). 2005, Registered Nurses Association of Ontario, (RNAO):
         Toronto. p. 136.
12. National Asthma Council Australia, (NACS), Asthma Management Handbook 2002. 2002, Canberra:
         Commonwealth Government Department of Health and Ageing.
13. McKenzie, D., COPD: interventions for better outcomes. Prescibing Practice Review, 2006. 33.
14. Australian Lung Foundation, (ALF),Australian Physiotherapy Association, (APA), Pulmonary Rehabilitation Kit. 2006,
         Australian Lung Foundation, (ALF)
Australian Physiotherapy Association, (APA).
15. Poole, PJ ,Black, PN, Mucolytic agents for chronic bronchitis or chronic obstructive pulmonary disease (Review).
         The Cochrane Library, 2006(2).
16. American Medical Directors Association, (AMDA), COPD management in the long-term care setting. 2003,
         American Medical Directors Association: Columbia (MD). p. 32.
17. Scottish Intercollegiate Guidelines Network , (SIGN),British Thoracic Society, (BTS), British guidelines on the
         management of asthma. 2003, London: SIGN and BTS.

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                                Clinical Information Sheet – Respiratory: Chronic Obstructive Pulmonary Disease
18. Asthma Victoria, (AV), Nebulisers, in http://www.asthma.org.au/informationsheets/nebulise.doc (accessed March
          2004), Victoria, Asthma. 2000
19. Institutes), National Institutes of Health (National Heart Lung and Blood, Considerations for Diagnosing and
          Managing Asthma in the Elderly. 1996, New York: U.S. Department of Health and Human Services.
20. Bochner, F, ed. Australian Medicines Handbook 2004. 2004, Hyde Park Press: Richmond, SA.
21. Australia, National Asthma Council, Asthma Management Handbook 2002. 2002, Canberra: Commonwealth
          Government Department of Health and Ageing.
22. Australia, Asthma, Asthma medications and delivery devices. 2003, Canberra: Asthma Australia.
23. Institutes), National Institutes of Health (National Heart Lung and Blood, Practical guide for the diagnosis and
          management of asthma. 1997, New York: U.S. Department of Health and Human Services.
24. Society, Scottish Intercollegiate Guidelines Network and British Thoracic, British guidelines on the management of
          asthma. 2003, London: SIGN and BTS.
25. Harmon-Weiss, S., Chronic obstructive pulmonary disease. Nutrition management for older adults. 2002, Nutrition
          Screening Initiative (NSI): Washington (DC). p. 11.
26. Nutrition Screening Initiative, (NSI), A physician’s guide to nutrition in chronic disease management for older adults.
          2002, Nutrition Screening Initiative, (NSI): Washington. p. 4.
27. Meek, P.,Lareau, S., Critical outcomes in pulmonary rehabilitation: Assessment
and evaluation of dyspnea and fatigue. Journal of Rehabilitation Research and Development, 2003. 40(5): p. 13-24.
28. Hébert, P., O’Connor, A., Aaron, S., Wilson, K., Dales, R., Fiset, V., Viola, R., McKim, D., The Use of Intubation and
          Mechanical Ventilation for Severe Chronic Obstructive Pulmonary Disease (COPD): A Decision aid for patients.
          2004, Ottowa: University of Ottowa.
29. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of
          clinical practice guidelines. 1995, Canberra: AGPS.

Levels of Evidence
Background information on the management of COPD provided in this Clinical Information Sheet
is based on Level I evidence produced by expert opinions in the field, particularly the 2006
Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary
Disease 2006 produced by The Australian Lung Foundation (ALF) and Thoracic Society of
Australia and New Zealand, (TSANZ). Supporting evidence is based on additional Level I
evidence, including guidelines produced by National Institute of Clinical Excellence (NICE) in the
UK and the Scottish Intercollegiate Guidelines Network (SIGN).

The following table outlines the level of evidence of each reference:

Ref No       Author                                                                     Year        Level Evidence
1            Harvey, P. et al                                                           2005        Level III
2            Karavatas, S.                                                              2005        Level IV C
3            Stoller, J.                                                                2002        Level IV C
4            McKenzie, D. et al                                                         2006        Level IV C
5            eTG                                                                        2005        Level IV C
6            Guidelines and Protocols Advisory Committee                                2005        Level I
7            National Institute for Clinical Excellence                                 2004        Level I
8            Institute for Clinical Systems Improvement                                 2005        Level I
9            Australian Lung Foundation et al                                           2006        Level I
10           Global Initiative for Chronic Obstructive Lung Disease                     2005        Level I
11           Australian Lung Foundation et al                                           2006        Level I
12           Registered Nurses Association of Ontario                                   2005        Level IV C
13           National Asthma Council Australia                                          2002        Level I
14           McKenzie, D.                                                               2006        Level IV C
15           American Medical Directors Association                                     2005        Level I
16           Poole, PJ and Black, PN                                                    2006        Level I
17           Scottish Intercollegiate Guidelines Network & British                      2003        Level I
             Thoracic Society
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18         Asthma Victoria                                                 2000      Level IV C
19         National Institutes of Health (National Heart Lung and          1996      Level IV C
           Blood Institutes)
20         Bochner, F, ed.                                                 2006      Level IV C
21         National Asthma Council Australia                               2002      Level I
22         Asthma Australia                                                2003      Level IV C
23         National Institutes of Health (National Heart Lung and          1997      Level IV C
           Blood Institutes)
24         Scottish Intercollegiate Guidelines Network, British            2003      Level I
           Thoracic Society
25         Harmon-Weiss, S                                                 2002      Level IV C
26         Nutrition Screening Initiative                                  2002      Level IV C
27         Meek, P et al                                                   2003      Level IV B
28         Hébert, P et al                                                 2004      Level IV C

Literature was identified through a standardised search for systematic reviews and clinical guidelines
published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in
CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to
relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [29]
scale for randomised control data and lower levels of evidence when RCT is not available. The scale
was adapted by adding a level of evidence (Level V) for non-referenced material, e.g. developed in
local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the
time of writing.

Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any
requirements of, or recommendations from professional registration groups or regulating bodies e.g.
NBV, RCNA, ANF, overseeing the residential aged care industry in Victoria, Australia. Readers
outside Victoria, Australia are advised to review the material in the context of their local legislation and
health system regulations.

It was developed using the process outlined in Section 5, and is provided under the terms of the
disclaimer in Section 1 of the GP and Residential Aged Care Kit:
http://nwmdgp.org.au/pages/after_hours/

For more detailed or up to date information than is provided in this CIS, please refer to cited sources
and current literature.

North West Melbourne Division of General Practice: http://www.nwmdgp.org.au/




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