COPD Advanced Nursing Guide

GOLD Spirometric Classification

Post-bronchodilator FEV1/FVC <0.7 confirms obstruction. Grade based on FEV1% predicted.

Grade	Severity	FEV1% Predicted
GOLD 1	Mild	≥80%
GOLD 2	Moderate	50–79%
GOLD 3	Severe	30–49%
GOLD 4	Very Severe	<30%

KEY FACT — Exam Tip

FEV1/FVC <0.7 post-bronchodilator is REQUIRED to diagnose COPD — spirometry is mandatory. Symptoms alone are insufficient.

GOLD ABCD Grouping

Combines symptom burden (CAT/mMRC) + exacerbation history to guide pharmacotherapy.

Group A

Low symptoms + Low risk
CAT <10 or mMRC 0–1
0–1 exacerbation/yr (no hosp)

Group B

More symptoms + Low risk
CAT ≥10 or mMRC ≥2
0–1 exacerbation/yr (no hosp)

Group E

High exacerbation risk
≥2 exacerbations/yr
OR ≥1 hospitalisation

NOTE (2023 Update)

Groups C & D merged into Group E in GOLD 2023 report. Know both old C/D and new E.

CAT Score (COPD Assessment Test)

8 items, each scored 0–5. Total 0–40. Higher = more impact.

8 DOMAINS (remember: CPTBBAHSE)

1. Cough frequency

2. Phlegm production

3. Tightness in chest

4. Breathlessness on hills

5. Breathless at home

6. Activity limitation

7. Home confidence

8. Sleep quality / Energy

<10

Low Impact

10–20

Medium

>20

High Impact

mMRC Scale & BODE Index

mMRC DYSPNOEA SCALE (0–4)

0Only breathless with strenuous exercise

1Short of breath when hurrying on level ground

2Walks slower than people of same age; stops after 15 min

3Stops for breath after 100m or a few minutes on level ground

4Too breathless to leave house; breathless when dressing

BODE INDEX (0–10 points — mortality predictor)

BMI (<21 scores 1)

Obstruction (FEV1%)

Dyspnoea (mMRC)

Exercise (6MWT metres)

Higher BODE = worse prognosis. Score ≥7 = high mortality risk. Used for transplant listing.

Baseline Assessment Investigations

SPIROMETRY

Post-bronchodilator FEV1/FVC <0.7
FEV1% predicted for severity
Bronchodilator reversibility test
Differentiates from asthma

IMAGING

CXR: hyperinflation, flat diaphragm, bullae
CT Chest: emphysema distribution/bullae
HRCT: bronchiectasis exclusion
Echo: cor pulmonale / pulmonary HTN

BLOOD / ABG

FBC: polycythaemia (hypoxaemia)
ABG: type 2 respiratory failure
Alpha-1 antitrypsin if <45yrs
BNP if cor pulmonale suspected

Bronchodilator Therapy

SABA — Short-Acting Beta-2 Agonist (Rescue)

Salbutamol 2.5mg nebulised / 100–200mcg MDI PRN · Ipratropium 500mcg neb (SAMA)

Rapid bronchodilation for acute symptoms. Used PRN — not regular scheduled use in stable COPD.

LAMA — Long-Acting Muscarinic Antagonist (Once Daily)

Tiotropium (Spiriva HandiHaler/Respimat) · Umeclidinium · Aclidinium · Glycopyrronium

Preferred first-line for Group A/B. Reduces exacerbation frequency. Dry powder or SMI inhalers. Caution: urinary retention, narrow-angle glaucoma.

LABA — Long-Acting Beta-2 Agonist (Twice Daily)

Salmeterol 50mcg BD · Formoterol 12mcg BD · Indacaterol (OD) · Olodaterol

Alternative first-line or combined with LAMA. Formoterol has fast onset — dual rescue and maintenance role.

LABA + LAMA COMBINATION — First-Line Most Symptomatic

Umeclidinium/vilanterol (Anoro) · Tiotropium/olodaterol (Spiolto) · Glycopyrronium/indacaterol (Ultibro)

Superior to monotherapy for symptom control and exacerbation prevention. Recommended Group B and most Group E patients.

ICS, Triple Therapy & Add-On

ICS — Inhaled Corticosteroids (Add-On Criteria)

Fluticasone · Budesonide · Beclomethasone

ADD ICS WHEN:

Blood eosinophils ≥300 cells/µL
History of asthma-COPD overlap
Frequent exacerbations despite LAMA+LABA

Risks: pneumonia (especially fluticasone), oral candidiasis, bone density reduction

TRIPLE THERAPY (LAMA+LABA+ICS)

Fluticasone/umeclidinium/vilanterol (Trelegy Ellipta) · Beclomethasone/glycopyrronium/formoterol (Trimbow)

IMPACT/ETHOS trials: significant exacerbation reduction vs dual. For persistent exacerbations on LAMA+LABA with eos ≥100.

ROFLUMILAST (PDE4 Inhibitor)

500mcg oral daily. Indication: FEV1 <50%, chronic bronchitis phenotype (productive cough), ≥2 exacerbations/year

Side effects: nausea, diarrhoea, weight loss, headache. NOT a bronchodilator — anti-inflammatory mechanism.

Non-Pharmacological Management

SMOKING CESSATION

Single most impactful intervention. Slows FEV1 decline to non-smoker rate. NRT, varenicline, bupropion, behavioural support. All healthcare contacts = cessation opportunity.

PULMONARY REHABILITATION

Minimum 20 supervised sessions. Exercise training (aerobic + resistance) + education + psychosocial. Reduces hospitalisations, improves QoL, mortality benefit. Indicated post-exacerbation within 4 weeks.

LTOT — LONG TERM O2

Criteria: PaO2 <7.3 kPa (55 mmHg) or SaO2 <88% on air — two ABGs 3 weeks apart when clinically stable. Minimum 15 hours/day. Reduces polycythaemia, pulmonary HTN, mortality.

Also at 7.3–8.0 kPa if + polycythaemia/oedema/pulm HTN

AECOPD Causes

TRACHEOBRONCHITIS Mnemonic

T — racheobronchitis (infection)

R — ight heart failure

A — tmospheric pollution

C — old weather

H — aemothorax/pneumothorax

E — mbolism (PE)

O — pioids/sedatives

B — ronchiectasis flare

R — espiratory muscle fatigue

O — ther — non-adherence

N — eoplasm / lung cancer

C — ardiac ischaemia

H — igh altitude / travel

I — nfluenza / viral

T — hermal extremes

I — nhaler non-adherence

S — inus infection

KEY STAT: Infection (bacterial/viral) accounts for 70–80% of AECOPD triggers. Streptococcus pneumoniae, H. influenzae, Moraxella catarrhalis most common bacteria.

DECAF Score — Severity

Predicts in-hospital mortality in AECOPD. Validated UK tool.

Variable	Criteria	Points
D — Dyspnoea	mMRC grade 5 (too breathless to leave house or dress)	1
E — Eosinopaenia	Eosinophils <0.05 × 10⁹/L	1
C — Consolidation	New consolidation on CXR	1
A — Acidaemia	pH <7.30 = 2pts; pH 7.30–7.34 = 1pt	1–2
F — AF	Atrial fibrillation on admission ECG	1

0–1

Low mortality ~1%

2–3

Moderate ~5–9%

4–6

High >25%

AECOPD Treatment Protocol

OXYGEN

Target SpO2 88–92%
28% Venturi start
Titrate 24–28–35% Venturi
Avoid uncontrolled O2
Risk: O2-driven hypercapnia
Check ABG after 30–60 min

NOT 98–100% — causes hypercapnic respiratory failure

BRONCHODILATORS

Salbutamol 2.5–5mg neb
Ipratropium 500mcg neb
Combined if severe
Repeat every 4–6h
IV aminophylline if refractory

Drive nebulisers with AIR not high-flow O2 (adjust separately)

CORTICOSTEROIDS

Prednisolone 30–40mg OD
Duration: 5 days
No added benefit >7 days
IV hydrocortisone if NBM
Monitor blood glucose

REDUCE-IT trial: 5 days = 14 days efficacy

ANTIBIOTICS

Anthonisen Criteria (2 of 3):

Purulent sputum
Increased sputum volume
Increased dyspnoea

1st: Amoxicillin 500mg TDS
Alt: Doxycycline / Clarithromycin
Severe/Resistant: Co-amoxiclav

INTERACTIVE TOOL

AECOPD Severity & Management Guide

Enter patient parameters to receive severity classification and immediate management guidance.

SpO2 (%)

ABG pH

PaCO2 (kPa)

RR (breaths/min)

Consciousness

Accessory Muscles

Complete Sentences?

NIV Indications & Contraindications

INDICATIONS (Must meet ALL criteria)

pH <7.35 (respiratory acidosis confirmed)
PaCO2 >6.0 kPa (hypercapnia)
Despite 20–30 min optimal medical treatment
Able to protect airway (GCS ≥8)
Able to tolerate mask
Reversible cause identified

Note: pH 7.25–7.35 = definite NIV · pH <7.25 = HDU/ICU discuss invasive ventilation

CONTRAINDICATIONS

Haemodynamic instability / cardiac arrest
Upper GI bleed (active)
Facial trauma / burns / recent surgery
Unable to cooperate or protect airway
Copious secretions — high aspiration risk
Fixed upper airway obstruction
Pneumothorax (undrained)
Vomiting with unprotected airway

BiPAP Settings & Targets

INITIAL SETTINGS

IPAP (Inspiratory)

12–16 cmH2O

Start at 12, titrate up by 2 every 10–15min. Max 20 cmH2O. Aim: adequate chest rise + improved tidal volume.

EPAP (Expiratory)

4–6 cmH2O

Counters auto-PEEP (air trapping). Increase if persistent O2 desaturation. Keep EPAP low to avoid hyperinflation.

FiO2 TITRATION ON NIV

Set supplemental O2 to maintain SpO2 88–92%. Do NOT use high-flow oxygen to drive BiPAP ventilator. Titrate blended O2 to target. Check ABG at 1 hour — if pH improving, continue NIV.

RESPONSE TARGETS AT 1 HOUR

pH improving towards 7.35+
PaCO2 decreasing (even modestly)
RR decreasing (<25 breaths/min)
Patient comfortable + synchronised
SpO2 within 88–92% range

Nursing Care on NIV — Key Responsibilities

MASK FITTING

Select correct mask size (oronasal preferred)
Fit over bridge of nose — no gap
Secure headstrap — not too tight
Inspect pressure areas: nose bridge, ears, cheeks hourly
Use prophylactic dressing on bridge of nose
Minimise air leak — check for hissing

CARE BUNDLE

Mouth care every 2 hours (NIV dries mucosa)
Scheduled breaks: medications, eating, suction
Insert NG tube if gastric distension (aerophagia)
Position upright: 45° minimum
Explain treatment — anxiolysis reduces fight
Monitor for worsening confusion

FAILURE CRITERIA — ESCALATE

No pH improvement at 1 hour
Worsening acidosis (pH <7.25)
Deteriorating consciousness
Increasing RR/work of breathing
Patient inability to tolerate mask
Haemodynamic instability

NIV failure = escalate to ITU for intubation OR initiate ACP/comfort-only care discussion

NIV Modalities — Key Differences

BiPAP (Bilevel PAP)

Two pressures: IPAP (inspiration) + EPAP (expiration)
Augments tidal volume — helps ventilation
Reduces PaCO2 — treats hypercapnia
Indication: AECOPD with type 2 respiratory failure
Improves pH, reduces intubation rate

CPAP (Continuous PAP)

Single continuous pressure throughout breath cycle
Splints airways — prevents alveolar collapse
Treats oxygenation failure — NOT hypercapnia
Indications: OSA, acute pulmonary oedema, COVID/ARDS
CPAP does NOT improve ventilation in COPD

EXAM CRITICAL: CPAP is NOT appropriate for AECOPD with hypercapnic failure. BiPAP is required. CPAP only addresses hypoxia — not the hypercapnia driving the acidosis in AECOPD.

Pulmonary Rehabilitation

PROGRAMME COMPONENTS

Exercise Component

Aerobic: walking/cycling 20–60 min
Resistance training (upper + lower)
Minimum 20 supervised sessions
2–3 sessions/week for 6–8 weeks

Education & Psychosocial

Inhaler technique, smoking cessation
Breathing techniques (pursed lip)
Energy conservation strategies
Anxiety & depression management

OUTCOME MEASURES

6MWT — 6-Min Walk Test pre/post

CAT/mMRC — symptom scores

HADS — anxiety & depression

SGRQ — quality of life tool

EVIDENCE BASE

Reduces hospital readmissions by 30–40%
Improves exercise capacity and QoL
Mortality benefit at 12 months post-exacerbation
Optimal window: within 4 weeks post-AECOPD discharge

Home Oxygen Therapy (LTOT)

LTOT CRITERIA

PaO2 <7.3 kPa on air when stable — definite
PaO2 7.3–8.0 kPa + polycythaemia / oedema / pulm HTN
TWO ABGs 3 weeks apart when clinically stable
Not smoking (fire hazard — absolute)
Minimum 15 hours per day use

EQUIPMENT OPTIONS

Concentrator (home static)
Portable concentrator (mobility)
Cylinders (back-up/ambulatory)
Liquid oxygen (exercise)

SAFETY EDUCATION

No smoking — 3m minimum from O2
No naked flames / open fires
Store cylinders upright/ventilated
Alert fire service of O2 in home

AMBULATORY OXYGEN

For exercise-limited patients who desaturate <88% on exertion. Assessed with 6MWT with and without O2. Separate prescription to LTOT.

End-Stage COPD (GOLD 4) & Palliative Care

ADVANCE CARE PLANNING

DNACPR discussion — document & review
Treatment escalation plan (TEP)
Patient preferences for intubation/NIV
Place of care / death preferences
Involve family + spiritual care
Register with palliative care team

ACP should be proactive — initiated at GOLD 3–4, not crisis

PALLIATIVE BREATHLESSNESS

Opioids (1st line):

Oral morphine 2.5–5mg PRN 4-hourly
Low-dose regular + PRN schedule
Titrate cautiously — start low

Anxiolytics:

Lorazepam 0.5–1mg SL PRN
Midazolam SC (syringe driver)
Manage dyspnoea-anxiety cycle

NIV AT END OF LIFE

Comfort-only NIV — symptomatic relief
NOT for prolongation of dying
Reduces dyspnoea sensation
Discussed with patient/family
Clearly documented in notes
Discontinue if causing distress

Hospice/community palliative care team referral early for continuity

GCC-Specific COPD Context

EPIDEMIOLOGY & RISK FACTORS

Smoking prevalence: 40–60% in Gulf males — major driver
Biomass fuel exposure (rural areas, cooking fires)
Sandstorm/dust exposure — occupational + environmental
Construction workers: silica/cement dust exposure
Kuwait oil fire legacy (1991) — firefighter COPD
COPD significantly underdiagnosed — normalised as "smoker's cough" or ageing

HEALTHCARE PATHWAYS

DHA (Dubai Health Authority) COPD care pathway — integrated primary/secondary care
DOH (Abu Dhabi) chronic disease management protocols
Pulmonary rehabilitation expanding but limited access vs UK/Europe
LTOT via concentrators available in private sector (home delivery)
Cylinder oxygen supply chain robust in KSA, UAE, Kuwait

RELIGIOUS & CULTURAL CONSIDERATIONS

Ramadan fasting & inhalers: Permissible — medications go to lungs, not stomach. Scholarly consensus (fatwa) supports use of inhaled medications during fasting.
Oxygen during fasting: Permissible — O2 is not food/drink, does not invalidate fast.
Nebulisers during Ramadan: Debated — some scholars advise caution if vapour inhaled; MDI preferred if equivalent.
Family-centred care model — involve family in COPD education
Modesty considerations for pulmonary rehabilitation (gender-separated PR available in GCC)

DHA · DOH · SCFHS Exam Prep

HIGH-YIELD EXAM FACTS

GOLD CLASSIFICATION

FEV1/FVC <0.7 post-bronchodilator = obstructive. GOLD 1=≥80%, 2=50–79%, 3=30–49%, 4=<30% FEV1% predicted.

CONTROLLED OXYGEN TARGETS

SpO2 88–92% in COPD. Use Venturi mask (28–35%). High-flow O2 causes CO2 retention. Never target 98–100%.

NIV INDICATIONS

pH <7.35 + PaCO2 >6 kPa after optimal medical treatment. BiPAP is appropriate. NOT CPAP. Check ABG at 1 hour.

LTOT CRITERIA

PaO2 <7.3 kPa on air (stable). TWO ABGs 3 weeks apart. Minimum 15 hours/day. Absolutely NO SMOKING on O2.

PREDNISOLONE IN AECOPD

30–40mg daily for 5 days. No benefit in extending beyond 7 days (REDUCE-IT). Monitor blood glucose.

EXAM PRACTICE

COPD MCQ Quick-Fire Review

Q1. A COPD patient presents with SpO2 82% on air. Which oxygen device and target is correct?

Q2. AECOPD ABG: pH 7.30, PaCO2 8.5 kPa after 30min treatment. What is the NEXT action?

Q3. LTOT is indicated when stable ABG shows PaO2 of:

Q4. Which inhaled therapy reduces COPD exacerbations but has risk of pneumonia?

COPD — Advanced Nursing Guide