Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and preve ntion of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Ca re Med 2007; 176(6): 532 \200\223555. Srivastava P, Currie GP, Britton J. Smoking cessation. BMJ 2006; 332(7553):1324 \200\2231326. Wedzicha JA, Seemungal TA. COPD exacerbations: de \201 ning their cause and prevention. Lancet 2007; 370(9589): 786 \200\223796. This page intentionally left blank R EVANS & M MORGAN 106 5.5 Non-pharmacological management for COPD In recent years it has become evident that COPD is a com- plicated systemic disease with co nsequences that go far beyond the damage to the airways. Pharmacological treat- ment for CO PD is disappointing in comparison to its central role in asthma. No pharmacological treatme nt convincingly modi \201 es the progress of the disease and the role of drug treatment is con \201 ned to amelioration of symptoms. The lack of effective pharmacological treatment has in the past resulted in a nihilistic attitude towards therapy that has only recently c hanged, alongside a greater understanding of the nature and development of disability in CO PD. The content of this chapter will cover the relevant areas of non-pharmacological treatm ent. Other important areas of non-pharmacological treatment such as smoking cessation and l ung volume reduction surgery are covered elsewhere in the book. \200 The nature and asses sment of disability in COPD. \200 Formal pulmonary rehabilitation. \200 Other forms of performance enhancement. \200 Self-management programs. Table 5.5.1 MRC Dyspnoea Scale Grade Degree of breathlessness related to activities 1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on the level ground because of breathlessness, or has to s top for breath when walking at own pace 4 Stops for breath after walking about 100m or after a few minutes on the level ground 5 Too breathless to leave the house, or breathless when dressing or undressing Other simple scales such as the Oxygen Cost Diagram exist but are not widely used. The attr action of the MRC scale is the simplicity to which it can be applied to clinical interview and broad acceptance of its validity. Health status \200 Quality of life (health status) questionnaires all differ in their con tent and emphasis. However, most disease- speci \201 c questionnaires contain domains that relate to activity limitation or dyspnoea on exertion. Nature and assessment of disability Breathlessness resulting in activity limitation (disabi lity) is a major feature of advanced COPD. In the early stages of the condition the mild ai r \202 ow obstruction may have no impact. However as air \202 ow obstruction or hyperin \202 ation pro- gresses, dyspnoea on exertion eventually becomes a signi \201 - cant featu re of daily life. These effects may be delayed until loss of airway function is quite advan ced. This is because people generally have a large reserve of pulmonary func- tion that may not be required by a modern lifestyle. In addition, people with exertional dyspnoea can li mit the sen- sation by avoiding the provoking stimulus. Subsequently the skeletal musculatu re may become de-conditioned as a con- sequence of activity avoidance and further compound the problem. Once disability ensues it can be compounded by loss of con \201 dence, low mo od and poor task performance. The onset of disability is therefore a complicated picture of airway pathophysiology that is compounded by skeletal muscle dysfunction and psychosocial in \202 uences. To date, the nature of the muscle dysfunction is thought probably to be co nsequent upon the de-conditioning. There is an argument for a speci \201 c in \202 ammato ry myopathy in COPD but this is dif \201 cult to sustain when muscle groups other than the quadriceps appear immune. Nevertheless the muscles in COPD are also vulnerable to the effe cts of hypoxia, poor nutrition and steroid medication or other potential myopathic agents. The most well known questionnaires are the Chronic Respiratory Questionnaire (CRQ) and the St George \200\231s respiratory questionnaire (SGRQ). These are both vali- dated and respon sive questionnaires that have been used as outcome assessments for studies of therapeutic i ntervention. The CRQ is a predominantly responsive questionnaire while the SGRQ has both discriminative and evaluative qualities. Other disease-speci \201 c questionnaires that speci \201 cally examine physical function ing such as the pulmonary function scale and dyspnoea questionnaire (PFSDQ) exist but are n ot so widely used All these questionnaires have value as outcome meas- ures in clinical trials. They can also be used for quality assurance purposes in a rehabilitation program. Unlike the MRC scale they do not have any value in the management of the individual case. Exercise tests Objective assessment of exercise capacity is possible with \201 eld and la boratory examinations. Well-known \201 eld walking tests that have been applied to COPD a re the 6-minute walk test (6MWT) and the shuttle walk tests. Assessing disability The relationship between airway function (FEV1) and dis- ability is po or and non-predictive. The assessment of dis- ability in COPD requires a speci \201 c appr oach. The options include dyspnoea scales, health status questionnaires and direct observat ion of exercise performance. 6MWT This simple self-paced walking test has been used exten- sively for evaluation. It has normal reference ranges and a de \201 ned minimally important clinical difference. Althou gh the test is in widespread use it has some disadvantages as a performance measure because of its vulnerability to learning and encouragement effects. The physiological challenge of the 6MWT is also unpredictable. Dyspnoea scales The MRC Dyspnoea Scale (Table 5.5.1) is the best known of simple rating sca les. This was originally developed as part of a wider questionnaire but has become a useful and rapidly applicable tool for clinical staging of disability. It is really an activity s cale rather than a dyspnoea scale. The format is simple with a 1 to 5 score. The modi \201 ed scale that is used in the USA has a 0 \200\2234 scale. The shuttle walk tests These were developed as the \201 eld equivalents of the maximal ca pacity and submaximal (endurance) laboratory exercise tests. The incremental shuttle walk t est (ISWT) involves walking around a coned 10m course at speeds that increase every minute. The endurance shuttle walk CHAPTER 5.5 Non-pharmacological management for COPD 107 test (ESWT) involves walking at a constant speed around the cones. Both are externally pace d and symptom limited. These tests are growing in popularity because they are less vulnerab le to the in \202 uences of learning and encourage- ment and the physiological challenge i s known. In contrast to the 6MWT, the ISWT has a graded physiological response. Recently a minimally clinical important difference has been de \201 ned. the form of cycling or brisk walking. Training schedules require a combination of intensity , duration and frequency. These principles are similar to exercise training in health. Pati ents with COPD can actually train at a higher relative proportion of their maximal oxygen u ptake than healthy people. This is because the usual cardiovascular limit to exercise is pr e-empted in many people with advanced COPD by a ventilatory limit imposed by dynamic hyperi n- \202 ation. Opinions vary as the correct prescription intensity of endurance training. Higher intensity (>60% VO2 peak) training produces better results, and genuine physiologi- cal training, than lower intensity training. However some health status bene \201 ts occu r even with low intensity activity. Laboratory exercise testing Metabolic laboratory exercise testing provides the most compreh ensive description of disability but the tech- nology may not be widely available. Usually the tests are conducted on a cycle ergometer for convenience though this may not be a natur al mode of exercise for elderly people. Maximal incremental exercise tests can provide a me asure of disability and an explanation of limitation. Endurance or constant workload tests, however, are a more sensitive re \202 ection of change induced by therapeutic interventio n. AUTHOR \200\231S TIP A key point is that the exercise prescription should be deliberate and incremented with time over duration of the training program. Formal pulmonary rehabilitation programs Since disease modi \201 cation cannot readily be achieved in COPD, the aims of therapy are to improve symptoms, functional status and qualit y of life. Secondary aims of treatment would include improvements in independence and reduc tion in health care burden. Once medical care has been optimized the aim of formal rehabili tation is to restore the individual to best possible social and physical functioning. Most of the evidence for the bene \201 t of reha- bilitation is derived from studies in patient s with COPD but there is a growing realization that similar bene \201 ts can be achieved i n people with disability from a variety of chronic respiratory diseases. The method of setting a prescription for exercise intensity is often poorly understood. One method is simply to mea- sure peak performance on a walking test or cycle and then to iden tify the speed or load to equate to the required relative workload (e.g 85% of peak predict ed VO2). The current recommendations for session duration (30 mins exercise per session) an d course length suggest that at least three sessions of training are required per week for a period of at least 4 weeks to have an effect. Two of the weekly sessions need to be super vised and further home based sessions are desirable. Strength training Training for strength alone can also produce similar bene- \201 ts in h ealth status and exercise performance to endur- ance training. Most programs will combine u pper and lower limb strength exercises with the aerobic (endur- ance) program. Strength (or resistance) training is per- formed on gym apparatus or uses free weights. In some severel y disabled patients it may simply be lifting their body weight. Once again an attempt shoul d be made to make a positive prescription for the training load. This is usually done on by the one repetition maximal (1RM) method where the prescription is set at 70% of the maxima l pos- sible contraction load. There are arguments for and against training on gym equipmen t and free weights. Obviously the multi-gym apparatus can provide greater precision and \202 exibility of exercises. On the other hand, patients cannot take the gym home with them so the free weights may be the more pragmatic solution. Overall concept Pulmonary rehabilitation programs with similar struc- tures have now become established in most countries. A formal rehabilitation program is distinguished from self- management or activity promotion program. It is also different from informal exercise class es of the type that may follow on from formal rehabilitation. In principle, a formal progra m should address the needs of the individual patient by involvement of a multiprofessional team, the patient and their relatives. There are various options for settings but the stage s of rehabilitation include assessment, core rehabilitation, re-assessment and maintenance. The content of a program includes physical exercise training, disease education and self- management. Assessment The rehabilitation process aims to improve disability and promote independence s o the appropriate individual assessments should include measures of physical function and h ealth status. Lung function would not be expected to change. At a population level, rehabil itation has been shown to reduce impact on hospital admission and may even have an impact o n survival. Upper body exercise Most of the described bene \201 ts of rehabilitation follow from lower limb exercise training. This is logical since upper limb strength is better preserved. How ever, there is some purpose in conducting upper limb training in order to improve activitie s of daily living. The literature on upper limb training alone suggests that upper limb tra ining can improve task performance but does not have any carry over effects on general exer cise performance or health status. Most programs will therefore include upper limb training in addition to lower limb training. This training will take the form of supported arm exer cise using an arm ergometer or other apparatus or unsupported exercises using free weights. Content Physical exercise training/endurance Individually prescribed, supervised, lower lim b physical training is a mandatory component of the program. Exclusion of physical training removes the bene \201 t. Most programs will offer a combination of lower limb endur- ance and strength training. Endurance training usually takes R EVANS & M MORGAN 108 Other patients to pick out would be those with clinical evidence of psychiatric illness or relationship dif \201 culties where counseling may be appropriate. Respiratory muscle training This remains a controversial subject that attracts support- ers and detractors. Current opinion supports the view that respiratory muscle function is rela tively well preserved in people with COPD and that speci \201 c respiratory muscle trainin g is unlikely to have wider bene \201 ts. In fact the trial evidence suggests that respira tory muscle training can improve respiratory muscle strength and task associated dyspnoea b ut does not improve general exercise perform- ance or health status. Supporters of respirat ory muscle training argue that trials seldom use suf \201 cient training loads or go on fo r long enough. When this is done there do appear to be some longer lasting bene \201 ts. F or the present, the addition of respiratory muscle training adds little to the general trai ning bene \201 ts. Suggested education content (accompanied by written material) \200 Disease management. \200 Devices and oxygen. \200 Relaxation. \200 Bene \201 ts advice. \200 Travel. \200 Sexual relations. \200 Smoking cessation. \200 Energy conservation. Speci \201 c psychological intervention There is considerable evidence to suggest that anxiety and depr ession commonly co-exist with COPD. The literature describes a wide range of prevalence of psychiatric morbid- ity and in some cases does not make a distinction between low mood asso ciated with chronic illness and a pathologi- cal state requiring speci \201 c treatment. C learly pathological states merit identi \201 cation and treatment on their own. The eviden ce for including speci \201 c psychological interven- tions such as cognitive behavioral t herapy in a rehabilitation program is less convincing. It is possible that behavior modi \201 cation may have an effect on speci \201 c areas such as smoking cessation or dyspnoea . However, the rehabilita- tion process itself offers substantial mood enhancing and anxiet y relieving bene \201 ts. This is mediated through the education sessions as well as the s upport provided by the group interactions. Oxygen during training This is an area of concern and interest for people involved in pulmo nary rehabilitation. There are two facets to consider. Firstly there is the aspect surround ing safety concerns in people who de-saturate on exercise and secondly the bene \201 t of oxygen itself as a training adjunct The safety pro \201 le of pulmonary rehabilitation is extremely good but it is dif \201 cult to feel comfortable about deliber- ately provoking hypoxaemia even if the patient is likely to do so at home. The second point about whether o xygen can enhance physical training is perhaps more interesting. Some studies have shown th at training on oxygen carries no additional bene \201 t but other have demonstrated that t raining on oxygen permits a higher load that should theoretically result in more ef \201 c ient training. In practice it is quite dif \201 - cult to arrange oxygen for people while they are training, especially if it involves brisk walking. Program organization and management There are obvious differences between the delivery of a rehabilitation program and the usual therapeutic interaction. The program requires a conti nuing active commitment from the patient and the synchronized involvement of a number of he alth care professionals. It is a principle of rehabilitation that the diagnosis is secure a nd that the patient is on optimal medical treatment. It is not the role of the rehabilitati on process to provide a diagnos- tic service or review medication. The service is delivered by a team that generally includes a medical representative, physiotherapist, occupational therapist, dietician, pharmacist and others. These can be supplemented by volunteers or rel atives. Some larger pro- grammes may include a sports scientist or psychologist in their te ams. There needs to be a speci \201 c role for a pro- gramme co-ordinator to manage timeta bling. AUTHOR \200\231S TIP From the safety perspective it is reasonable to offer oxygen to patien ts who de-saturate (SpO2 <85%) during supervised treatment. Disease education and self-management Physical training is the major component of rehabilit ation but it needs to be supported by an educational program. This may take the form of lec tures or discussion topics around aspects of lung disease and self-management. These sessio ns are provided by the relevant members of the multiprofessional team. It is important to e ncourage rela- tives and carers to attend these sessions so that they too have an understan ding of the condition and the principles of rehabilitation. The education sessions offer an opportu- nity to select patients who have special speci \201 c needs. Continuing smokers, if willing, can be directed to the smok- ing cessation service. Smoking and rehabilitation are con- troversial areas. Some authorities recommend that current smokers should not be o ffered rehabilitation because they are known to have a higher drop out rate. However, smok- ers do derive exactly the same bene \201 ts from rehabilitation if they stick to the cour se. Our policy would be to accept current smokers but offer targeted smoking cessation. The re are other groups that may require speci \201 c atten- tion and referral. These include those with excessive sputum production who need physiotherapy advice. Safety and quality assurance Staf \201 ng ratios for rehabilitation classes are set to ens ure ef \201 ciency and safety. A reasonable staf \201 ng level would be to ensure that th ere are at least one member of staff for eight patients in an exercise class or 1:16 for th e education classes. For safety purposes it is recommended that there are at least two memb ers of staff present at all times. There are no reports of adverse events associated with r ehabilita- tion but it is sensible to take precautions with staff having current resuscitat ion skills and available equipment. Quality assurance is an important component of any serv - ice delivery. In rehabilitation several parameters can be used to monitor program quality . Individual patients will have assessments of functional capacity and health status CHAPTER 5.5 Non-pharmacological management for COPD 109 There should be evidence of program quality control on entry and completion. This data can be used to monitor the effectiveness of the program. Other monitoring can be derived from patient satisfaction questionnaires and records of at tendance and drop out. and improvement. Other forms of performance enhancement Transcutaneous electrical muscle stimulation Physica l training is the most popular form of muscular con- ditioning but other methods of improvi ng muscle function exist. One method is transcutaneous electrical muscle stimulation which conditions muscles by means of super \201 - cial electrodes. These are generally available over the counter but have been used in trials of rehabilitation in COPD. At least three ra ndomized controlled trials have shown improvements in muscle strength and walking dis- tanc e that compare favorably with active physical training. The precise role of this type of mu scular conditioning is uncertain but it is possible to see a role for these devices in immo bile patients during exacerbation or those recov- ering on intensive care units. Setting and accessibility Successful rehabilitation programs have been described in various settings. These include hospital outpatient, hospital inpatient, community centers and eve n within the patient \200\231s home. The choice of setting is not as important as the skill s and enthusiasm of the staff. Accessibility for the patient is a critical determinant of u ptake and contin- ued commitment. In this case transportation arrangements are often critic al to the success of the program. Careful choice in site of the program and awareness of tr ans- port is a major consideration. So too is the timing of the sessions. People with COPD are not at their best \201 rst thing in the morning so a later start is welcome. Seasonal changes may also have in \202 uence since spontaneous physi- cal activity is less in the winter. Ultimately the choice of venue may be determined by cost. At present, hospital out- patient rehabilitation is the most cost effective because of the availability of staff and infrastructure. However, the lack of capacity compared to demand for rehabilitation should lead to the development of active community based rehabilitation. Such programs are likely to be as effec- tive but must also adhere to the same principles of quality control. Nutrition and pharmaceutical agents \200 Patients with COPD who have nutritional depletio n (BMI <19 or FFM <16) are greater risk of death than those who maintain their body weight and muscle mass. \200 Nutritional support would be a logical therapy to improve prognosis but supplementation alone does not appear to be effective. This is likely to be because gi ving people nutritional supplements does not necessarily guarantee calorie supplementation. An alternative is to consider dietary supplementation during physical training to enhance t he increase in mus- cle mass. This seems to work, as it does in athletes and in people with normal body weight. However, it does not have any effect on the target population who are depleted. Timing of rehabilitation The best timing for entry in to a rehabilitation program is when p atients are in a stable phase and able to attend the program without interruption. There ar e also other times when adapted forms of rehabilitation are appropri- ate. There have been successful reports of rehabilitation being delivered immediately after a hospital admission . Another occasion where intervention may be valuable is during the hospital admission itse lf where the inactivity associated with the enforced rest may be detrimental and could be o ffset by timely intervention. It is possible that by this stage the nutritional changes are irreversible by anything but lung volume reduction or transplantation. In most rehabilitation programs obesity is a bigger problem than nutritional depletion. In this case the dieti- cian \200\231s advice must be tailored to the individual needs. \200 There are a number of pharmaceutical agents that are reputed to enhance physical performan ce in athletes. It is reasonable to explore this route of pharmaceutical performance enhanc ement in patients with impaired mobility. Trials have been conducted with anabolic ster- oi ds and nutritional supplements such as creatine. Anabolic agents do appear to increase musc le bulk but this does not translate into improved physical perform- ance or health status. Maintenance programs The purpose of rehabilitation is to induce a lifestyle change that mai ntains the improvement. These immediate bene \201 ts of rehabilitation may remain for 12 \200\22318 months and then diminish with disease progression. It is not known for certain w hether maintenance programs or repeated courses can retain the bene \201 t for longer. The literature suggests that maintenance programs or repeated programs can have a short term e ffect but no prolonged effect can yet be demonstrated. Nevertheless patients do appear to e njoy post-rehabilitation exercise classes and these may be best considered as part of the s elf management approach to activity promotion. Similarly, the bene \201 ts of nutritional supplements com- bined with physical training s eem meager. By contrast, training on long-acting anticholinergic bronchodilator therapy doe s appear to have an additive effect. Walking aids The provision of mobility aids to people with advanced disability seems quite natural in patients with neurological or orthopedic disease but is often forgotten in those who are disabled by breathlessness. However, walking aids have been shown to be useful in patients with COPD. The use of rollators or wheeled walkers is associated with increased wa lking distance especially in the most disabled patients. In spite of improved performance, not everybody that improves their walking performance with the walking aid will subsequentl y continue to use the device. However, those that persevere, continue to \201 nd them use ful. Key features of a rehabilitation program \200 A rehabilitation program must contain indiv idually prescribed, physical exercise training together with lifestyle and self-management advice. The program should be delivered by a multi- disciplinary team and include two supervised se ssions per week for at least four weeks. Further home training should be encouraged. Individual progress should be assessed by the use of appropriate assessment and outcome mea sures (usually health status and functional exercise capacity). R EVANS & M MORGAN 110 educated self-management for the majority of patients with COPD. More severe patients will require more active case- management. One of the dif \201 culties with the research data t o date is that the reported self-management programs have had different strategies. For exa mple, the education components may comprise of verbally delivered informa- tion, written or other visual aids. The program may also offer different levels of advice about physical ac tivity and become confused with formal rehabilitation. These confounding approaches are pro bably responsible for some of the uncertainties. Future studies should clarify the situatio n. Another area of potential confusion is the distinction between formal rehabilitation and the promotion of physi- cal activity. Formal rehabilitation programs are a speci \201 c c ourse of therapy that has the aim of restoring physical functioning and well-being. These p rograms are de \201 ned, structured, supervised and time limited. However, outside of the boundaries of the rehabilitation program the promotion of physical activity is vital advice . In COPD, reduced physical activity is linked to mortality and hospital admission. Every o pportunity should be taken to encour- age the patient to remain active and challenge their breath- lessness in order to retain their \201 tness. This advice should also be applied to people at the end of their rehabilita- tion program so that they can more easily retain the bene \201 t. Miscellaneous methods of improving dyspnoea Surgical techniques to reduce dynamic hyperin \202 ation (lung volume reduction and bullectomy) have a role in selected patients with het erogeneous emphysema and static hyper- in \202 ation. These are dealed with elsewhere in t his book. Breathing retraining is not as effective in COPD as it is in dysfunctional breath ing or asthma. In particular, there seems to be no role for teaching diaphragmatic breathin g or similar techniques. However some patients with emphy- sema do learn to use pursed lip breathing as a method of reducing \202 ow limitation by increasing end-expiratory air- wa y pressure. Most patients develop this habit naturally but it is possible that they can be taught if necessary. Distressing dyspnoea may also be helped by distractive stimuli or lear ned behavior. Disease education in the course of the rehabilitation program may teach patie nts relaxa- tion techniques or strategies to limit dyspnoea. Examples of dyspnoea-limiting techniques include resting against a wall while supporting the shoulder girdle or using the supermarket trolley to provide similar support whist shopping. It is claimed that much of the bene \201 t obtained from short burst oxygen in non-hypoxic patients may simply be the effect of air \202 owing on the face. This can be reproduced by a simple hand-held fan. Finally, the observation that joggers use portable music players while running has stimulat ed research to show that patients with COPD can get similar bene \201 t from such distract ive stimuli. Further reading Pulmonary rehabilitation. Thorax 2001; 56: 827 \200\223834. Chronic obstruc tive pulmonary disease. National clinical guideline on management of chronic obstructive pu lmonary disease in adults in primary and secondary care. Thorax 2004; 59 (Suppl 1): 1 \200 \223232. Self-management programs As with all chronic diseases a degree of self-management is likely to improve health outcomes. This is certainly true with asthma and would, for example, be fully accepted as part of the management of bronchiectasis and cystic \201 bro- sis. Howe ver, the value of self-management programs remains undetermined in COPD. In theory, a forma l pro- gramme of remote supervision and disease education accompanied by action plans for e xacerbations would be expected to produce obvious bene \201 ts. To date, the results sugge st that they probably do marginally improve health outcomes and reduce health care consumpt ion. This is a very important area of study because the future delivery of services for COP D will inevitably involve some form of Lacasse Y, Goldstein R, Lasserson TJ, et al. Pulmonary rehabilitation for chronic obstructi ve pulmonary disease. Cochrane Database Syst Rev 2006; 4: CD003793. Nici L, Donner C, Wouters E, et al. American Thoracic Society/ European Respiratory Society statement on pulmonary rehabili- tation. Am J Respir Crit Care Med 2006; 173: 1390 \200 \2231413. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidenc e-Based Clinical Practice Guidelines. Chest 2007; 131: 4 \200\22342. Troosters T, Casaburi R, Gosselink R, Decramer M. Pulmonary rehabilitation in chronic obstr uctive pulmonary disease. Am J Respir Crit Care Med 2005; 172: 19 \200\22338. This page intentionally left blank J HURST & J WEDZICHA 112 5.6 Management of an exacerbation of COPD Introduction Exacerbations of COPD cause much of the morbidity, mortality and therefore hea lth-care costs associated with this prevalent disease. In general, exacerbations become bot h more frequent and more severe as the severity of the underlying COPD increases. However, some patients appear more susceptible to these events than others and patients who experien ce frequent exacerbations (two or more courses of antibiotics and or corticosteroids per ye ar) have a more rapid decline in lung function, poorer quality of life and higher mortality . It is particularly impor- tant to target these patients for the preventative therapies de scribed below. The following tests are usually appropriate in a hospital setting: \200 FBC. \200 U&Es. \200 Blood glucose (steroid-associated hyperglycaemia). \200 CRP. Whilst CRP is not us eful in con \201 rming diagnosis, it may help in monitoring the response to therapy. 12-lead ECG. \200 CXR. This should be no different from a radiograph when the patient is stable, but may show features of underlying COPD such as hyper-expansion and pulmo- nary ar tery enlargement. The major reason to perform the radiograph is to exclude alternative caus es of dysp- noea in a patient with underlying COPD. General management principles 1. Make the diagnosis. Exacerbation of COPD is a clinical dia gnosis of exclusion \200\223 there is no diagnostic test. It is important to consider, and where appropriate exclude other possible causes of breathlessness in a patient with underl ying COPD, for example pneumonia, pulmonary embolus, pneumothorax and cardiac failure. ABG. The following tests are generally unhelpful: \200 Sputum culture, as the presence of bacteria in sputum does not imply causation. Many patients have the same species of bacter ia in sputum even when clinically stable, a phenomenon called \200\230bacterial coloni- sa tion \200\231. The most common isolates are Haemophilus influenzae, treptococcus pneumoniae and Moraxella catarrhalis 2. Assess severity. Whilst there is no uniformly accepted method of assessing exacerbation severity, clinical assess- ment is important to judge the intensity of the treatment requir ed, and the need for hospital care. In general, the presence of new onset respiratory failu re, the need for treatment unavailable in the community, multiple co-morbidities or the abs ence of adequate social sup- port all indicate the need for specialist assessment and possi ble hospital admission. LFTs including serial peak-expiratory \202 ow measure- ments, as the changes in individua l patients are small, and the tests are dif \201 cult to perform in patients who are acute ly dyspnoeic. Therapy Fig. 5.6.2 summarizes the disease-modifying, and supportive aspects of therapy at e xacerbation of COPD, described in further detail in later sections. It is important to emph asize the need for prompt therapy: this reduces exacerbation length which is one measure of exacerbation severity. 3. Institute treatment. Therapy is administered step-wise, described further below, and fol lowing the basic principles illustrated in Fig. 5.6.1 that includes disease-modifying treat ments, interventions designed to support respiratory function until such disease-modifying treatments have had time to act, assessment and treatment of co-morbidities, and the instit ution of appropriate preventative strategies to reduce the risk of further exacerbation. Supportive therapy Increasing severity Increase dose/frequency of bronchodilators Controlled oxygen Disease- modifying therapies Attention to co-morbidities Supportive therapies Add systematic corticosteroids Prophylactic anticoagulation Fluid balance Management principles at an exacerbation of COPD Add antibiotics (if a change in the character of sputum) Non-invasive ventilation Invasive ventilation Consider adding additional therapies, e.g. theophyllines Palliative interventions Assess need for preventative therapies Disease-modifying therapy Management co-morbidities Fig. 5.6.2 Disease-modifying and supportive aspects of therapy Fig. 5.6.1 Basic principles of therapy Disease-modifying therapy Bronchodilators \200 Some exacerbations will respond to an incr eased use of bronchodilators alone, including B2-agonists and anti-cholinergic drugs, and t his forms the basis of therapy in all exacerbations. These drugs target the additional Investigations The purpose of investigations at exacerbation of COPD is to provide addition al information in excluding other diagnoses, identifying co-morbidities and assessing exace rbation severity. CHAPTER 5.6 Management of an exacerbation of COPD 113 An aminopenicillin, tetracycline or quinolone would be a reasonable empiric choice, though local resistance pat- terns should be considered. bronchoconstriction and hyperin \202 ation present at exac- erbation, which is presumed to result from increased airway in \202 ammation. Intravenous therapy is rarely required. \200 7 \200\22310 days of therapy is generally ad equate. Additional therapies \200 Methyxanthines, usually IV aminophylline, may be used i n patients not responding to the described measures, although evidence of bene \201 t from these drugs is generally absent. Theophyllines are said to have a variety of effects on th e respiratory, cardiovascular and immune systems which are of potential benefit during exac erbations. Against this, the narrow therapeutic index, side effects and drug interactions m ake administration dif \201 cult. Short-acting B2-agonists are preferred as they have a more rapid rate of action than short- acting anti-cholinergics. \200 Although most guidelines suggest the use of both classes o f drug together when the response to one or other is inadequate, there is in fact no eviden ce that this is supe- rior to B2-agonists alone. There is also no evidence that nebulisers are superior to administration via an inhaler and spacer. Nebulisation may be preferred in patients who are acutely dyspnoeic. The nebuliser driving gas should be prescribed, and is usually air with any additional oxygen administer ed separately. \200 Long-acting bronchodilator drugs have no role acutely, but patients p rescribed long-acting B2-agonists when stable would normally continue on such therapy. It i s not recommended that patients receive both long- and short- acting anti-cholinergics simu ltaneously but the bene \201 ts of one therapy over the other have not been reported. \200 There is no evidence supporting the use of intravenous The use of central respiratory stimulants has declined with the availability of non-invasiv e ventilation (NIV). Doxapram is still occasionally used as a holding measure prior to NIV, when NIV is inappropriate or unavailable, or (with specialist advice) in conjunction with NIV. There is currently no de \201 ned role for mucolytics at exacerbation of COPD. salbutamol at exacerbation of COPD. Sputum clearance techniques and nebulised saline are also not supported by available eviden ce and therefore not recommended routinely. Systemic corticosteroids \200 These drugs should be added in all exacerbations not respon ding to an increase in bronchodilators alone. The rationale is to attenuate the additional airway in \202 amma- tion that occurs during exacerbations, and which results in the sympt omatic and physiological deterioration. \200 The most robust evidence suggests that these drugs improve the rate of recovery of lung function, but effects on other outcome measures are more variable, and there is no evidence of a mortality bene \201 t. There is no strong data to support the use of leukot- riene receptor antagonists, intraveno us magnesium or Heliox (helium and oxygen) at exacerbation of COPD. Controlled oxygen Oxygen therapy is indicated in all exacerbations associated with respirat ory failure. This may be the result of a severe exacerbation in a patient with milder under lying disease, or be pre-existing in those with more advanced COPD. As a proportion of pati ents with COPD are at risk of developing hypercapnia with high- \202 ow oxygen, oxygen sho uld be administered at the minimum concentration able to maintain saturations at 90 \200 \22392%. Failure to achieve this without a rise in PaCO2 or fall in pH suggests the need fo r ventilatory support. Most guidelines recommend 30 \200\22340mg of prednisone for between 10 \200\22314 days, lon ger courses (and tapering the dose) are not of additional bene \201 t and are associ- ated with a greater chance of side-effects, especially hyperglycaemia. Nebulised budesonide appears equally effective to oral dosing but is more expensive.