Symptoms

• Worsening of cough
• Worsening dyspnoea
• Wheezing
• Increase in sputum volume, tenacity (difficult expectoration) and purulence
• Acute confusion
• Pyrexia (often)

Signs

• Tachypnoea
• Tachycardia
• Prominent abdominal movement
• Pursed lip breathing, tracheal tug, prolonged expiration
• Predominant use of accessory muscles
• Inspiratory or expiratory wheezes
• Look for signs of cor pulmonale
• peripheral oedema, raised jugular venous pressure, hepatomegaly
• Look for signs of uncompensated type 2 respiratory failure
• drowsiness, confusion, cyanosis, flapping tremor, papilloedema

Investigations

• Arterial blood gases (ABG) when breathing air
• if clinical condition does not allow ABG when breathing air, record FiO₂
• Chest X-ray
• ECG
• Sputum (inspect for purulence and viscosity, and send for culture)
• FBC
• If suggestion of systemic infection, blood cultures - see Collection of blood culture specimens guideline
• U&E
• CRP

Differential diagnosis

• Pneumonia (consolidation on Chest X-ray). See Community-acquired pneumonia guideline
• Exacerbation of asthma - if in doubt treat as such - See Asthma guideline
• Pneumothorax - even small can be dangerous. See Spontaneous pneumothorax guideline
• Left ventricular failure - see Heart failure guideline
• Pulmonary embolism - see Haemodynamically stable (submassive) pulmonary embolism and Haemodynamically unstable (massive) pulmonary embolism  guidelines
• Drug-induced deterioration in respiratory function
• review for sedatives and beta-blockers

• Document in medical record patient's functional status before the exacerbation
• A senior physician must document patient's ventilation and resuscitation status
• Oxygen. See Hypoxaemia guideline
• Correct dehydration

Antimicrobials

• If patient has new, unexplained Chest X-ray shadowing, follow antimicrobial regimen in Community-acquired pneumonia guideline
• Check computer for recent sputum microbiology results
  • if last culture report within 3 months treat according to sensitivities
  • if sensitivities not known treat according to empirical regimen below
• Usual organisms: Strep. pneumoniae, H. influenzae, Moraxella catarrhalis
  • if influenza prevalent, consider Staph. aureus

Penicillin Allergy

• True penicillin allergy is rare
• Ask the patient and record what happened when they were given penicillin
• If any doubt about whether patient is truly allergic to penicillin, seek advice from a microbiologist or consultant in infectious diseases

Infection Control alerts

• Check for IC alert
  
  • If IC alert not available, check previous 12 months of microbiology reports
• If MRSA present, treat as tagged for MRSA. See MRSA management
• If ESBL, MGNB, CARB present, treat as tagged for ESBL. See ESBL/MGNB/CARB management

Antimicrobial empirical regimen

• Doxycycline 200 mg oral on first day, then 100 mg oral daily
  • avoid oral zinc, calcium, iron, salts and antacids containing magnesium or aluminium within 2 hr of doxycycline)
  • if patient unable to swallow or absorb oral antimicrobial, co-amoxiclav 1.2 g IV 8-hrly, or
  • if penicillin allergic, clarithromycin 500 mg IV by infusion into larger proximal vein 12-hrly
  • statins contraindicated in combination with clarithromycin (see current BNF for other interactions)

Bronchodilators

• Salbutamol (2.5 mg) or terbutaline (5 mg) via air-driven nebuliser 4-6 hrly
• Consider adding ipratropium bromide (500 microgram) via nebuliser 6-hrly
• If not improving after 4 hr, add aminophylline infusion - see Aminophylline guideline

Corticosteroid

• Prednisolone 30 mg oral daily
• If already taking maintenance (long-term) dose of prednisolone, increase daily dose by 30 mg
• If severely ill, give hydrocortisone 100 mg by slow IV bolus 6-hrly until able to take oral steroids

Physiotherapy

• Only aids clearance of sputum

Mechanical ventilation

• See Respiratory failure guideline

• Admit to a respiratory ward
• Refer all patients to the oxygen and respiratory service for review within 24 hr of admission

Improving after 48 hr

• Continue with oral antimicrobials until sputum mucoid
• Continue nebulised bronchodilator if already using at home or check inhaler technique and substitute appropriate inhaler device for nebulised bronchodilator(s)
• Continue prednisolone at same dose for 5-14 days before stopping or returning to maintenance dose
• no need to taper withdrawal unless repeated or recent prolonged courses
• If either PaO₂ >7.3 kPa or SpO₂ >92% while breathing air, stop oxygen but watch for deterioration
• If patient conscious and not confused, and has no unstable concurrent clinical conditions, refer to the oxygen and respiratory team for assessment of home care

Not improving after 48 hr

• Consider resistant organisms. Change antimicrobial based on sputum culture result, where known
• Consider underlying disease (e.g. bronchogenic carcinoma, bronchiectasis)

• Peak expiratory flow (PEF) - aim to attain patient's 'best' PEF when well (if known)
• ABG - see Respiratory failure guideline
• Sputum volume and conversion from mucopurulent/purulent to mucoid
• Subjective improvement of dyspnoea
• Objective improvement as reflected by increased exercise tolerance

• Check inhaler technique when changing from nebuliser therapy to metered dose inhaler or spacer devices
• Refer to oxygen and respiratory service who will check inhaler technique, and
• if appropriate, refer on to the community respiratory team for pulmonary rehabilitation and oxygen assessments 
• Review home medication
• Advise smokers to stop smoking
• Advise to see own doctor whenever sputum becomes purulent
• Advise GP to arrange prophylactic influenza vaccination annually and offer pneumococcal vaccination if not already given
• Consider providing rescue pack for future exacerbations – discuss with supported early discharge team or refer to respiratory services
• If chest X-ray suggests consolidation, repeat as outpatient after 6 weeks