Chronic Obstructive Pulmonary Disorder (COPD) is a preventable chronic inflammatory pulmonary illness that obstructs the airflow in the lungs. Hence, a COPD Exacerbation is referring to the sudden worsening of symptoms that leaves patients with a suffocating feeling. In fact, when patients experience a COPD Exacerbation, they often present with extreme dyspnoea, a productive cough and an overwhelming feeling of anxiety.
In this article we’ll be going over the Nursing Management of COPD Exacerbations, but before we get into that, make sure that you’ve understood the:
What causes a COPD Exacerbation?
Given that COPD is a chronic illness, most people presenting with an exacerbation would have already been on long-term regular treatment. However, when patients with COPD come across viral respiratory infections such as the common cold, influenza or COVID their regular treatment would not be enough.
If you’ve understood the pathophysiology of COPD then you know that the patient’s body gets an abnormal inflammatory reaction to respiratory irritants, and this is still the case here. During an exacerbation, the patient’s body reacts abnormally to a viral infection or an environmental trigger and as a result the symptoms will become worse and worse. The airways become narrower, the mucus production increases and the overall flow of oxygen is decreased.
So in short, a COPD Exacerbation can be triggered by:
Viral respiratory infections (Common cold, Influenza, COVID)
Bacterial respiratory infections (Sinusitis, Bronchitis, Pneumonia)
Environmental triggers (Smoking, air pollution, dust)
What are the signs and symptoms of a COPD Exacerbation?
Depending on the patient, exacerbations may take hours, days or weeks to progress. Symptoms include:
Fatigue becomes worse, often affecting activities of daily life
Cough becomes more frequent, persistent and productive
Increase in mucus amount
Change in mucus colour (from clear to a dark yellow, green or brown)
Difficulty breathing even when at rest
Low SPO2
Symptoms of a cold (headache, fever)
Now that we’ve understood what a COPD Exacerbation is, let’s have a look at the nurse’s role and how to manage these patients.
Nursing Management for COPD Exacerbation
COPD Exacerbation Nursing Assessment Part 1: Health History
During an exacerbation it’s important to take a step back and actually understand when it started, and what triggered it. Start off by introducing yourself to the patient, and find a private area to initiate the assessment. Once the patient is comfortable, you can start off by asking about their exposure to risk factors. Specific questions about the type, intensity and duration of exposure will give you a clear indication of what triggered the condition. You might want to ask:
Whether the patient smokes, is around second-hand smoke or has environmental pollutants at work/home
How often are they exposed to the irritant? How long have they been exposed to it?
Do they have a history of hospitalizations for respiratory problems?
Next up, you should ask your patient about their past medical history specifically about any previous respiratory conditions, including allergies, asthma, sinus infections or nasal polyps. This should also include their closest family relatives, so note down the patient’s family history in relation to respiratory illnesses.
Once you’ve established a good understanding of the patient’s background you can move on to assess the current situation and how the COPD symptoms are affecting your patient’s life. Ask your patient when they can first recall experiencing any respiratory-related symptoms, if they’ve noticed a pattern of symptom development and whether they occur only during exercise or at rest as well. You might want to ask:
Which symptoms do they notice first?
Does the shortness of breath become worse when exercising?
How much exercise can they tolerate?
Are they experiencing any pain, and if so where? Is the pain interfering with their daily routine?
Have they noticed any changes in their eating and sleeping routines?
Lastly, you should ask questions to understand the patient’s knowledge and current management about the condition as well as their social and familial support system.
Once you’ve obtained a thorough medical history, you can move on to the physical assessment to get a better understanding of the patient’s physiological status.
COPD Exacerbation Nursing Assessment Part 2: Physical Assessment
Start off by taking a quick look at your patient’s position, both when sitting and standing. In most cases, patients with COPD would rest their hands onto their knees to support their breathing. Next up, you can take their hands and check:
Pulse
Oxygen Saturation
Clubbing of fingers
Record everything onto the patient’s file and move on to assessing their Respirations:
Are the respirations forced?
Can the patient finish off a sentence in one breath?
Are they contracting their abdominal muscles, or using their shoulders during inhalation?
Is the expiration time prolonged?
Can you note any unusual breath sounds? (Wheezing/ Crackles)
Most patients will present with a Cough, if you note that it’s productive you should also assess their Sputum in terms of colour, amount and consistency.
Along with the physical assessment, there’s a series of tests that the patient will be asked to perform. These tests will determine the severity of the disease and guide the medical team when selecting the treatment.
COPD Exacerbation Nursing Assessment Part 3: Medical Tests
The following tests will help you determine your patient’s physiological status:
Temperature: Exacerbation may be triggered by a respiratory infection
Respiratory Rate: Patient might be hyperventilating due to anxiety
Pulse Oximeter: Patient will most likely have low oxygen saturation in view of inadequate oxygen intake
Blood pressure: Should be within limits, might be high due to anxiety or low if patient is sweating and has fluid loss
Arterial Blood Gas: To have a baseline measurement of the patient’s oxygenation and gas exchange.
Spirometry: To evaluate airflow obstruction. The FEV1 is expected to be low since the obstruction will interfere with exhalation.
Pulmonary Function Studies will confirm the diagnosis, its severity and monitor the disease progression.
Chest X-ray: To exclude any other conditions
Blood Test: To check electrolytes balance, and screen for Alpha1-Antitrypsin deficiency
CT-Scan: This is rarely done for a COPD exacerbation. But, it might be ordered if there is suspicion of other diagnosis such as Tuberculosis, Heart Failure or Bronchiectasis.
Holistic Evaluation: Exacerbations are stressful, so make sure to check your patient’s overall well being and psychological state. You can do this by asking him if he needs any support and if he has any concerns.
COPD Exacerbation Nursing Diagnosis
From your assessment, you might find the following nursing diagnosis:
Ineffective airway clearance
Ineffective respirations
Impaired gas exchange
Inadequate nutrition
Activity intolerance
Deficient knowledge
Anxiety
COPD Exacerbation Nursing Care Plans
1. Managing Ineffective Airway Clearance
If your patient has ineffective airway clearance it means that they do not have a patent (open) airway. In the case of a COPD Exacerbation, this would typically be caused by a build-up of mucus in the airways, narrowing of the airways and a persistent cough.
Instruct your patient to sit in an elevated position, either on the chair or by elevating the bed and have the chin parallel to the floor or tilted slightly upwards to obtain an open airway. Once the position is set, encourage your patient to breathe using the pursed-lip technique. This technique makes it easier to breathe during an exacerbation, reduces air trapping and gives a sense of control to your patient.
The next step would be to help your patient get rid of the build-up of secretions in the airways. Teach them how to cough up secretions effectively and how to perform deep breathing exercises to maximise ventilation. You should also ensure that they’re adequately hydrated, as fluids make secretions less viscous and easier to be expectorated. Chest physiotherapy is very useful in preventing aspiration of secretions and further complications. Lastly, if your patient can not remove secretions alone you should use a Suction Set and remove them manually.
Patients with ineffective airway clearance might also be prescribed Mucolytic Agents to decrease the viscosity of secretions, and Bronchodilators to decrease the narrowing of the airways. They might also be prescribed antibiotics if the exacerbation was triggered by an infection.
2. Managing Ineffective Respirations
As we’ve explained in the Pathophysiology of COPD, the illness damages every structure in the lungs and respiratory system. This damage will often cause ineffective respiration which means that the patient would have wheezing, subcostal retraction and increased but shallow respiration.
Start off by ensuring that your patient has a clear airway and that they’re sitting at an elevated angle, especially when lying in bed. You should instruct the patient to use a pillow and splint their chest when coughing, this will provide support and allow the patient to inhale fully. Use deep breathing techniques to help the patient regulate their respiratory rate, and if necessary administer oxygen therapy as prescribed.
Moreover, administer the treatment as prescribed. Bronchodilators might be used to release bronchospasm, distribute more oxygen into the lungs and improve alveolar ventilation. And corticosteroids or combination therapy may be used to decrease the inflammation of the airways.
3. Managing Impaired Gas Exchange
If your patient isn’t clearing their airway effectively and isn’t breathing well either then it’s only fair to assume that they are also experiencing an impaired gas exchange. In fact, one of the secondary problems of COPD is known as dead space (a damaged area in the alveoli that does not allow oxygen and carbon dioxide to switch). This leads to an imbalance in the Ventilation-Perfusion Ratio (the amount of oxygen that is inhaled vs the amount of oxygen that makes it through the alveoli and into the body).
Ensure that the patient’s airway is cleared, continue nursing at an elevated angle and use a splint when coughing. Administer oxygen therapy as prescribed, keeping in mind that COPD patients use their hypoxic drive to breathe. This means that the oxygen concentration should be as low as possible, and it can easily be done through the use of a Venturi Mask. You should also encourage your patient to use nasal prongs during meal times, and a portable oxygen tank when moving around.
Non-Invasive Positive Pressure Ventilation (NIPPV) Machines might be indicated during sleep or in severe cases even during the day. NIPPV Machines push oxygen into the lungs, forcing it to perfuse through the alveoli and into the blood. This forces the gases to regain their balance allowing the Ventilation-Perfusion Ratio to return to normal.
It’s important to regularly monitor your patient if impaired gas exchange is present as if it’s not treated effectively it will lead to further complications. So look out for any signs of cyanosis, changes in mental status, abnormal ABG results, or abnormal vital signs because they can all indicate a deterioration in the patient’s physiological status.
4. Managing Inadequate Nutrition
Patients with severe COPD especially those having an exacerbation will often have inadequate nutrition because dyspnoea affects their eating habits. Eating becomes stressful and tiring, so they start to eat smaller portions. Moreover, secretions could also make it difficult for patients to swallow the food.
Ensure that the patient gets a rest period before and after eating, position them upright and maintain a clear airway. Provide high calorie meals or meal replacements such as shakes that come in small volumes, and encourage the patient to drink sport drinks that have additional electrolytes. You should also provide the patient with nasal prongs to supplement oxygen while they’re eating.
If these steps are not enough, the patient might need additional support such as intravenous fluids and enteral feeding.
5. Managing Activity Intolerance
Much like dyspnoea interferes with eating, it will also interfere with the patient’s activities of daily living and their social life.
Assess the patient’s needs and figure out what their individual concerns are, and then find coping mechanisms that work for that patient. Teach the patient to plan their activities, so they can schedule a rest period before and after each activity. Explain that they can use energy-conserving techniques such as using an electric wheelchair instead of walking long distances and using assistive devices to pick things up from the floor or high surfaces.
Teach your patients breathing exercises and low impact physical exercises to rebuild their stamina and regain independence. In some hospitals, you could also refer the patient to a pulmonary rehab specialist so they can learn to cope with their condition over time.
6. Managing Knowledge Deficiency
In some cases, exacerbations can be avoided but it’s almost impossible to avoid them if the patient doesn’t understand the disease in the first place.
Once all the urgent diagnoses have been dealt with, you should take time to sit down with your patient and talk about COPD. Start by asking the patient and their relatives what they know about the condition, its triggers and how to avoid them.
Highlight the connection between tobacco smoking and worsening of COPD, as well as the other environmental triggers. Especially how the common cold and other respiratory infections affect an individual with COPD more severely. In fact, it is recommended that COPD patients take the yearly influenza and COVID vaccine to avoid exacerbations.
Lastly, ask about their treatment adherence and explain why it is important. If you identify any challenges that stop the patient from adhering to the treatment you should discuss ways to overcome them and also inform the medical team.
7. Managing Anxiety
Many patients who have experienced COPD Exacerbation say that it felt as if they were suffocating and that they were scared they might die. Such an experience will increase stress and anxiety levels, and unfortunately, most patients would be too scared to open up about these feelings. Often because they do not want to seem childish or they don’t want to burden others with their worries.
As their nurse, you should create a safe space where your patient can voice their feelings and express their concerns. Explain the situation to the patient, what symptoms they have and how you’re treating them. Give them an expected timeline of when they can start to feel relief from the symptoms and how they are progressing. Use deep breathing exercised and the pursed-lip technique to regain control of their breathing, as well as distraction techniques to shift their focus onto other things.
COPD Exacerbation Nursing Discharge
After having gone through all the diagnoses and management, you will need to re-evaluate the situation and see if there’s been any improvement or deterioration in your patient. If you don’t notice any improvement, or you notice that your patient’s overall condition is worsening you will need to contact the medical team and alter the treatment plan accordingly.
But if your patient improves you can plan their discharge to ensure that they regain independence and avoid future exacerbations.
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