X3. Refer appropriately to prevent further deterioration (‘P’)

The risk of death from exacerbations of COPD increases with acute carbon dioxide retention (respiratory acidosis), the presence of significant comorbid conditions (eg, ischae­mic heart disease) and complications (eg, pneumonia and empyema). Depending on the nature and severity of the exacerbation, the patient may require urgent specialist review, hospital assessment or admission to a high-depend­ency or intensive care facility for ventilatory support and appropriate monitoring (see Box 9 and Box 10).

Box 9: Indications for hospitalisation of patients with chronic obstructive pulmonary disease

Marked increase in intensity of symptoms

Patient has acute exacerbation characterised by increased dyspnoea, cough or sputum production, plus one or more of the following:

  • Inadequate response to ambulatory management
  • Inability to walk between rooms when previously mobile
  • Inability to eat or sleep because of dyspnoea
  • Cannot manage at home even with home-care resources
  • High risk comorbidity condition – pulmonary (eg, pneumonia) or non-pulmonary
  • Altered mental status suggestive of hypercapnia
  • Worsening hypoxaemia or cor pulmonale
  • Newly occurring arrhythmia
Box 10: Indications for non-invasive or invasive ventilation
  • Severe dyspnoea that responds inadequately to initial emergency therapy
  • Confusion, lethargy or evidence of hypoventilation
  • Persistent or worsening hypoxaemia despite supplemental oxygen, worsening hypercapnia (PaCO2 > 70 mmHg), or severe or worsening respiratory acidosis (blood pH < 7.3)
  • Assisted mechanical ventilation is required.