PLAB 2: Mastering Acute COPD Exacerbation Guidelines

PLAB 2 Respiratory: Mastering Acute COPD Exacerbation Guidelines

Acute exacerbations of Chronic Obstructive Pulmonary Disease (COPD) are a staple of the PLAB 2 OSCE exam. These stations test not only your clinical knowledge but, crucially, your ability to apply UK-based guidelines swiftly, communicate empathetically, and manage risk effectively. Mastering the current guidelines (often reflecting NICE or BTS recommendations) is essential for securing a pass.

Why COPD Exacerbations are High-Yield for PLAB 2

COPD is highly prevalent, and managing its acute decompensation is a bread-and-butter scenario for any doctor working in the NHS, especially in primary care or A&E. In a PLAB 2 station, you will be expected to rapidly assess severity, initiate appropriate treatment, and ensure safe disposition.

1. Rapid Assessment: Identifying the Exacerbation

Your history taking must be focused and targeted to confirm the diagnosis and assess severity. Key questions to ask include:

• Classic Symptoms: Increased breathlessness, increased cough, and change in sputum production (volume/colour).

• Severity Markers: Current level of breathlessness (can they speak in full sentences?), use of accessory muscles, recent decline in exercise tolerance.

• Background: Smoking status, baseline spirometry results (if known), frequency of previous exacerbations, and need for home oxygen or non-invasive ventilation (NIV).

• Trigger: Look for signs of underlying infection, exposure to irritants, or recent medication changes.

OSCE Tip: If the patient is very breathless, prioritize essential history and move quickly to examination and management. Always offer supplemental oxygen if the patient appears distressed, pending SpO2 reading.

2. Physical Examination Essentials

In the exam, quickly perform a focused respiratory examination, paying attention to:

• Vitals: Respiratory rate (high RR suggests severity), heart rate, temperature, and Blood Pressure.

• Oxygen Saturation (SpO2): Crucial for determining oxygen therapy goals (see below).

• Auscultation: Decreased breath sounds (may indicate hyperinflation or collapse) and wheeze.

• Signs of Severity: Central cyanosis, confusion, use of accessory muscles, and paradoxical abdominal breathing.

3. Immediate Management Guidelines (The ABCs of COPD)

UK guidelines prioritize controlled oxygen, bronchodilation, systemic steroids, and antibiotics when indicated.

A. Oxygen Therapy (Crucial)

For most patients with known or suspected COPD, the oxygen target saturation is 88–92%. This prevents hypercapnic respiratory failure in chronic CO2 retainers. If the patient is not a known CO2 retainer, standard 94–98% may be used, but this must be justified.

• Delivery: Start with Venturi mask (e.g., 24% or 28%) to achieve the target range.

B. Bronchodilators

Administer immediate bronchodilator therapy, usually via nebuliser, as this delivers a higher dose quickly.

• First-line: Salbutamol (short-acting beta-agonist) and Ipratropium Bromide (short-acting muscarinic antagonist) combined.

• Dose example: Salbutamol 5mg neb, and Ipratropium 500 mcg neb, repeated as necessary.

C. Systemic Steroids

Oral corticosteroids are essential for reducing inflammation and improving outcomes in moderate-to-severe exacerbations.

• Drug/Dose: Prednisolone 30mg daily for 5 days. Ensure you check for contraindications (e.g., active GI bleed).

D. Antibiotics (When to Prescribe)

Antibiotics are not required for every exacerbation. They are indicated if the patient meets the "Anthonisen criteria" (or similar guideline criteria):

1. Increased breathlessness (Dyspnoea)

2. Increased sputum volume

3. Increased sputum purulence (colour change)

Prescribe antibiotics if the patient has:

• Sputum purulence plus increased breathlessness (or increased volume).

• Requires mechanical ventilation.

• Clinical signs of pneumonia.

• First-line choice (if infection suspected): Amoxicillin or Doxycycline (if penicillin allergy or atypical infection suspected).

4. Safety Netting and Disposition (The PLAB 2 Pass)

This is where many candidates lose marks. You must clearly articulate when the patient needs admission or further referral, especially if managing the patient in a simulated primary care setting.

Criteria for Urgent Hospital Admission:

Safety Netting Advice (for non-admitted patients):

• "If your breathing gets worse, if you become confused, or if you develop chest pain, you must call 999 immediately or return to the hospital/clinic."

• Explain how to use the prescribed medications (steroids and antibiotics) and when to follow up with their GP/COPD nurse.

Summary Table for PLAB 2 Focus