How should I manage a patient with chronic bronchitis who presents with an exacerbation?

When a patient with chronic bronchitis presents with an exacerbation, the management involves recognising the symptoms, assessing severity, and determining the appropriate level of care, often guided by a pre-existing self-management plan ¹,².

• Recognising an Exacerbation: An exacerbation is a sustained worsening of the patient's usual stable symptoms, acute in onset, and beyond normal day-to-day variations ². Common symptoms include worsening breathlessness, cough, increased sputum production, and a change in sputum colour, often necessitating a change in medication ². Exacerbations can be classified as mild (increased need for medication, self-managed), moderate (requires systemic corticosteroids and/or antibiotics), or severe (requires hospitalisation) ².
• Assessing Need for Hospital Treatment: Consider hospital admission if the patient experiences a rapid deterioration in respiratory status, a new arrhythmia, failure of the exacerbation to respond to initial treatment, is already receiving long-term oxygen therapy, or has changes on a chest X-ray ¹,². Hospital-at-home schemes may be an appropriate alternative to admission where available ¹.
• Managing Exacerbations in Primary Care (if admission is not indicated):
  • Bronchodilators: Advise the person to increase the doses or frequency of short-acting bronchodilators, ensuring not to exceed the maximum dose ¹. If possible, maintain the same delivery system (inhaler, inhaler with spacer, or nebuliser) as used on a day-to-day basis ¹. A nebuliser may be appropriate if the person is likely to become fatigued ¹.
  • Oral Corticosteroids: Consider oral corticosteroids for people with a significant increase in breathlessness that interferes with daily activities ¹. Offer 30 mg oral prednisolone once daily for 5 days ¹. Discuss the adverse effects of prolonged therapy and consider osteoporosis prophylaxis for those requiring frequent courses (3–4 courses per year) ¹.
  • Antibiotics: Oral antibiotics may be required for moderate exacerbations ². Short courses of oral antibiotics can be offered to people to keep at home as part of their exacerbation action plan if they have had an exacerbation within the last year and remain at risk ².
  • Oxygen Therapy: Optimal oxygen therapy is essential during assessment and transfer to hospital for acutely breathless patients ¹. Be aware that excessive oxygen can be dangerous in some people with advanced COPD, potentially worsening hypercapnic respiratory failure and respiratory acidosis; target saturation is needed ¹. Oxygen alert cards and 24% or 28% Venturi masks should be issued to people with COPD who have had an episode of hypercapnic respiratory failure ¹.
• Self-Management and Exacerbation Action Plans: Develop an individualised self-management plan in collaboration with the patient and their family/carers, providing personalised information on early recognition and management of exacerbations ¹,². This plan should include how to adjust short-acting bronchodilator therapy, when to contact a healthcare professional, and when to take prescribed short courses of oral corticosteroids and antibiotics kept at home ¹.
• When to Seek Specialist Advice: Seek specialist advice if symptoms are not improving with repeated courses of antibiotics, bacteria resistant to oral antibiotics are identified, or the person cannot take oral medication ¹. Referral to secondary care may be considered for additional therapies like roflumilast or long-term antibiotics ¹.
• Monitoring Recovery: Monitor recovery through regular clinical assessment of symptoms and observation of functional capacity ². Use pulse oximetry to monitor recovery in people with non-hypercapnic, non-acidotic respiratory failure ². For those with hypercapnic or acidotic respiratory failure, use intermittent arterial blood gas measurements until stable ². Routine daily monitoring of peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1) is not recommended for monitoring recovery ².