COPD exacerbation: recognition and management

An exacerbation of chronic obstructive pulmonary disease is an acute worsening of breathlessness, cough or sputum that goes beyond the patient's usual day-to-day variation, is set off most often by a viral or bacterial airway infection or by air pollution, and can tip lungs that have no reserve into hypercapnic respiratory failure, so the nurse recognizes it against the patient's own baseline rather than against a healthy one -- the patient who cannot finish a sentence, sleep lying flat or manage the usual walk, whose sputum has grown in volume or turned purulent, and whose reliever no longer lasts -- grades its severity from the clinical picture at presentation rather than from how it ends up being treated, the respiratory rate and heart rate, the work of breathing, the saturation and the level of consciousness, keeps in mind that pneumonia, a pulmonary embolus, heart failure and a pneumothorax present the same way and are looked for when the patient does not respond, and acts in order: sitting the patient upright, giving controlled oxygen titrated to the lower target saturation range prescribed for the patient at risk of hypercapnia rather than to a healthy reading, and never withholding it from a hypoxemic patient, giving the short-acting bronchodilator by inhaler or by a nebulizer driven by air rather than by oxygen, continuous monitoring, an arterial blood gas whenever the patient is drowsy, confused or not improving, and early escalation; carries the drug treatment safely -- the short course of a systemic corticosteroid that shortens recovery and needs no taper but raises the blood glucose, the antibiotic given only where the sputum has become purulent alongside more breathlessness or more sputum, or where the patient needs ventilatory support, rather than for every exacerbation, the maintenance inhalers continued, and no sedative or opioid for the restlessness, which is hypoxemia and hypercapnia and not anxiety; watches for the deterioration that is the real danger -- a rising carbon dioxide announcing itself as headache, a flushed warm skin, a bounding pulse, a flapping tremor, confusion and then drowsiness, or as accessory muscles, paradoxical breathing, a chest going quiet and a respiratory rate that falls because the patient is exhausted rather than better, which calls for noninvasive ventilation as the first-line support for hypercapnic respiratory failure with acidosis and for the team who will intubate if it fails -- while knowing that the exacerbation is not over when the breathing eases, because death, readmission and cardiovascular events cluster in the weeks that follow, so the patient goes home only when able to walk, eat and sleep, stable on the maintenance regimen with the inhaler technique checked, the need for oxygen reassessed, a written action plan, a referral to pulmonary rehabilitation and follow-up within the month.