PROBLEMS AND PROTOCOLS
The primary disorders for patients presenting to the hospital with exacerbation of chronic bronchitis are hypoxemia and excessive bronchial secretions. Therefore the protocols that should be immediately implemented would be the oxygen therapy and bronchopulmonary hygiene protocols - with the type and frequency dependent on the severity of the patient's presentation. The inflammatory response triggered by infection indicates the application of bronchodilators (with anticholinergics, or a combination of beta adrenergic and anticholinergic, often being more effective) and the delivery of an aerosolized anti-inflammatory (corticosteroid).
Infections can result in pneumonia and consolidation - which would indicate the need for hyperinflation protocol implementation.
Identification of Severity
The evidence based guideline from the American College of Chest Physicians is the standard for differentiation between mild, moderate, and severe exacerbations, and selection of relevant treatment.
Patient's are assessed for the diagnostic criteria of:
- Increase in dyspnea
- Increase in sputum volume
- Increase in sputum purulence
If one of the diagnostic criteria above is present the patient is evaluated for the presence of the following symptoms, if one is present this is identified as a mild exacerbation, with treatment with inhaled bronchodilators:
- URI in the past 5 days
- Fever without apparent cause
- Increased wheezing
- Increased cough
- 20% increase in heart rate or respiratory rate over baseline
If two of the diagnostic criteria above are present this is identified as a moderate exacerbation with treatment with inhaled bronchodilators plus the addition of systemic corticosteroids, oxygen therapy as needed, and non-invasive positive pressure ventilation as needed.
If three of the diagnostic criteria above are present this is identified as severe exacerbation, with the addition of antibiotics to the treatments given for moderate exacerbation.
Staging of COPD is also based on pulmonary function as given in Table 11-2
TABLE 11-2 Therapy at Each Stage of COPD (GOLD)
(Des Jardins, Terry. Clinical Manifestations and Assessment of Respiratory Disease, 5th Edition. C.V. Mosby, 112005.).
Note that in the management of mild to severe exacerbations of COPD (including Chronic Bronchitis and Emphysema) that chest physiotherapy, and mucolytics are not given as treatment options. This seems contradictory to the bronchopulmonary hygiene protocol indicated by excessive secretions. This does not mean that all bronchopulmonary hygiene treatments should not be used. CPT is very stressful to a patient who is hypoxic and hyperinflated - and is much like trying to pound ketchup out of a small bottle neck - and usually not worth the stress. Flutter valve, increased humidification (both systemic with increased oral intake of fluids, and inhaled with bland aerosol therapy), and supported deep breathing exercises with controlled cough will facilitate secretion clearance. Mucolytics may be ineffective on the type of secretions, can cause airway irritation and bronchospasm, and in general have not been proven effective in controlled studies.