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Chronic obstructive pulmonary disease - Management
When should I arrange hospital admission for a person with an acute exacerbation of COPD?

  • Most people with an exacerbation can be managed at home. However, some people need hospital admission for interventions that are not available at home such as oxygen, nebulizers, intravenous antibiotics, or ventilation.
  • Consider hospital admission if any of the following are present:
    • Severe breathlessness, rapid onset, confusion, cyanosis, worsening peripheral oedema, or impaired consciousness.
    • The person is unable to cope or lives alone.
    • Their general condition is poor or deteriorating (poor activity, confined to bed, or on long-term oxygen therapy).
    • Significant comorbidity (particularly cardiac disease or type 1 diabetes mellitus).
    • A low oxygen saturation (less than 90%).
      • Ensure that pulse oximetry is available.
    • New acute changes on chest x-ray, if requested and available locally and urgently. X-ray is mainly requested mainly to exclude alternative or concomitant diagnoses, for example bronchopneumonia.
  • Hospital-at-home schemes, provided by community respiratory teams, may be available in some areas and are an alternative to hospital admission.
    • Follow locally agreed care pathways.
      • Data are insufficient to make firm recommendations about which patients with an exacerbation are most suitable for hospital-at-home.
    • Hospital-at-home schemes may be suitable for people with few of the above indications for hospital admission who prefer treatment at home.
  • Whilst awaiting transfer to hospital, check oxygen saturation on air in people with a severe acute exacerbation and give oxygen (if available) if less than 90%. If available, refer to local protocols. If local protocols are unavailable:
    • Follow instructions on an oxygen alert card (if the person has been given one because of a previous episode of hypercapnic respiratory failure).
    • If the person does not have an oxygen alert card, use a 28% Venturi mask at a flow rate of 4 L/min, and aim for an oxygen saturation of 88–92%.
      • If the oxygen saturation remains below 88% despite a 28% Venturi mask, change to nasal cannulae at 2–6 L/min or a simple mask at 5 L/min with target saturation of 88–92%. In this situation, request an emergency ambulance and alert the accident and emergency department or medical admissions unit that the patient requires immediate senior assessment on arrival.
      • If the oxygen saturation decreases after commencing oxygen, change to a 24% Venturi mask at a flow rate of 2 L/min.

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