Standardisation of Clinical Assessment, Management and Follow-Up of Acute Hospitalised Exacerbation of COPD: A Europe-Wide Consensus

Figures & data

Figure 1 Schematic illustrating the Delphi survey process.

Table 1 Recommended Symptom Data Capture at Time of Hospitalised Exacerbation

Must Be Recorded
Symptoms	How to Measure	Frequency
Dyspnoea	Severity scale	Daily
Wheeze	Binary	Daily
Increased sputum volume	Binary	Daily
Sputum purulence	No consensus achieved	Daily
Cough	No consensus achieved	Daily
Fever	Binary	Twice a day to daily
Use of rescue medication	Severity scale	Daily
Increased inhaler use	Binary	Daily
Reduced exercise tolerance	Severity scale	Daily to once in admission
Confusion	Binary	Daily
Loss of consciousness	Binary	Daily
Orthopnoea	Binary	Daily to once in admission
Consider Recording
Chest tightness	Binary	Daily
Chest pain	Binary	Daily
Haemoptysis	Binary	Daily
Cough at night	Binary	Daily
Myalgia	Binary	Daily
Fatigue	Binary	Daily
Drowsiness	Binary	Daily
Poor appetite	Binary	Daily
Palpitations	Binary	Daily
Sore throat	Binary	Daily
Runny nose	Binary	Daily
Headache	Binary	Daily

Table 2 Recommended Clinical Signs Data Capture at Time of Hospitalised Exacerbation

Clinical Signs	Inclusion	Frequency
Blood oxygen saturation	Must	At least once every 4 to 12 hours
Supplemental oxygen amount	Must	At least once every 12 hours
Heart rate	Must	At least once every 12 hours
Respiratory rate	Must	At least once every 12 to 24 hours
Use of accessory respiratory muscles	Must	At least once every 12 to 24 hours
Change in mental state	Must	At least once every 12 to 24 hours
Blood pressure	Must	At least once every 12 to 24 hours
Temperature	Must	At least once every 12 to 24 hours
Wheeze on assessment/examination	Must	At least once every 12 to 24 hours
Irregular pulse	Must	At least once every 12 to 24 hours
Silent chest	Must	At least once every 12 to 24 hours
Orthopnoea	Must	At least once every 12 to 24 hours
Crackles	Must	At least once a day
Ronchi	Must	At least once a day
Pursed lip breathing	Must	At least once a day
Ankle oedema	Must	At least once a day
Presence of raised JVP	Must	At least once a day
Colour of sputum	Must	At least once a day
Body mass index	Must	Once during admission
Degree of raised JVP	Consider	Once a day to once during admission
Heart murmurs	Consider	Once a day to once during admission
Hoover’s sign	Consider	Once a day to once during admission
Weight	Consider	Once a day to once during admission
Pulsus paradoxus	Consider	Once a day to once during admission

Abbreviation: JVP, jugular venous pressure.

Table 3 Recommended Tests to Perform at Time of Hospitalised Exacerbation of COPD

Tests	Inclusion	Within 4 Hours	Within 8 Hours	Within 12 Hours	Within 24 Hours	Within Admission
Full blood count	Must	✓
Urea, electrolytes, creatinine	Must	✓
Troponin	Must	✓
BNP	Must	✓
CRP	Must	✓
Glucose	Must	No consensus achieved on time to first test
Liver function tests	Must	No consensus achieved on time to first test
ABG	Must	No consensus achieved on time to first test
Chest X-ray	Must	As soon as possible during admission
Electrocardiogram	Must	As soon as possible during admission
Echocardiogram	Must	No consensus achieved on time to first test
Sputum MCS	Must	No consensus achieved on time to first test
Influenza viral throat swab	Must	No consensus achieved on time to first test
6-minute walk test	Must	No consensus achieved on time to first test
Lactate dehydrogenase	Consider	No consensus achieved on time to first test
High-sensitivity CRP	Consider	No consensus achieved on time to first test
Procalcitonin	Consider	No consensus achieved on time to first test
Urine dipstick	Consider	No consensus achieved on time to first test
Viral throat swab	Consider	No consensus achieved on time to first test
CT scan of thorax	Consider	No consensus achieved on time to first test
Grip strength	Consider	No consensus achieved on time to first test
Quadricep strength	Consider	No consensus achieved on time to first test
Overnight oximetry	Consider	No consensus achieved on time to first test

Abbreviations: BNP, brain natriuretic peptide; CRP, C-reactive protein; ABG, arterial blood gas; MCS, microscopy, culture and sensitivities; DLCO, diffusing capacity of lung for carbon monoxide; CT, computed tomography.

Table 4 Recommended Clinical Scores and Questionnaires to Be Taken at Time of Hospitalised Exacerbation

Clinical Score/Questionnaires	Inclusion	Frequency
mMRC dyspnoea index	Must	At the start and end of admission
COPD assessment test	Must	At the start and end of admission
Frequent exacerbator phenotype	Must	Once during admission
BODEx	Consider	Once during admission
CURB-65	Consider	Once during admission
Glasgow Coma Scale	Consider	Once during admission
GOLD I–IV	Consider	Once during admission
GOLD A–D	Consider	Once during admission
Visual analogue scale for symptoms	Consider	At the start and end of admission
Early warning chart*	Consider	Daily
HADS*	Consider	Once during admission
DECAF*	Consider	Once during admission
Clinical COPD questionnaire*	Consider	No consensus achieved

Notes: *European experts felt that these scores may not be feasible in some centres. References for clinical scores and questionnaires listed in Supplementary Table 4.

Abbreviations: mMRC, modified Medical Research Council; BODEx, body mass index, degree of airflow obstruction, dyspnoea, exacerbations; CURB-65, confusion, urea, respiratory rate, blood pressure, age >65; GOLD, global initiative for chronic obstructive lung disease; HADS, hospital anxiety and depression scale; DECAF, dyspnoea, eosinopenia, consolidation, acidemia and atrial fibrillation.

Table 5 Recommendations Regarding Treatment Allocation, if Indicated, at the Time of Hospitalised Exacerbation of COPD

Treatment	Within 30 Minutes	Within 60 Minutes	Within 4 Hours	Within 24 Hours
Oxygen	✓
Nebulised short-acting beta agonists	✓
Nebulised short-acting muscarinic agents	✓
Systemic corticosteroids		✓
Intravenous fluids		✓
Non-invasive ventilation		✓
Antibiotics			✓
Opiates			✓
Diuretics			✓
Chest physiotherapy				✓
Assisted mobilisation				✓

Table 6 Recommended Treatment Failure Assessments at 30 Days After Hospitalised Exacerbation of COPD

Treatment Failure Outcome to Assess	Inclusion
Mortality	Must
Intensive care admission requirement	Must
Re-admission	Must
Re-treatment with steroids and/or antibiotics for COPD exacerbation	Must
Health care utilisation (any of hospital presentation, primary care or urgent care visit)	Must
Length of stay	Must
New or worsening co-morbidities following the index exacerbation event (eg, diabetes, osteoporosis)	Must
Increase in short-acting inhaled therapy	Must
Cumulative use of systemic steroids	Must
Change in symptom scores	Consider
Quality of life scores	Consider