What is the initial assessment and treatment approach for patients presenting with respiratory disorders?

Initial Assessment and Treatment Approach for Respiratory Disorders

The initial assessment of patients with respiratory disorders should focus on identifying potential red flags for sepsis or other serious illness, with appropriate safety netting advice for those who can self-manage their symptoms. 1

Initial Assessment

History and Vital Signs

• Assess for severity of symptoms including breathlessness, confusion (new or increased), which may indicate lower respiratory tract infection requiring further investigation 1
• Evaluate respiratory rate (≥30 breaths/min indicates high risk), blood pressure (systolic <90 mmHg or diastolic ≤60 mmHg indicates high risk), and presence of confusion (mental test score ≤8 or new disorientation) 1
• Consider the CRB65 score for risk assessment of pneumonia, which stratifies 30-day mortality risk based on Confusion, Respiratory rate, Blood pressure, and age ≥65 1

Physical Examination

• Look for signs of respiratory distress including use of accessory muscles, cyanosis, peripheral edema, and confusion 2
• Assess for signs of severe exacerbation that may require hospitalization, including marked increase in symptom intensity and new physical signs 2
• Consider the patient's overall health and social circumstances, as the threshold for treatment or referral may be lower for people with comorbidities, multimorbidity, or frailty 1

Initial Investigations

• Urgent investigations should include arterial blood gases, chest radiography, full blood count, urea, electrolytes, and electrocardiogram 2
• If purulent sputum is present, it should be sent for culture, and if pneumonia is suspected, blood cultures are recommended 2

Treatment Approach

Oxygen Therapy

• Provide supplemental oxygen to maintain PaO₂ >60 mmHg without causing respiratory acidosis 2
• For patients over 50 years with COPD, start with low-flow oxygen (28% via Venturi mask or 2 L/min via nasal cannulae) until arterial blood gases are available 2
• Monitor response with arterial blood gases within 60 minutes of starting oxygen therapy and after any change in oxygen concentration 2

Bronchodilator Therapy

• Short-acting inhaled β₂-agonists with or without short-acting anticholinergics are recommended as initial bronchodilators 2
• For moderate exacerbations, administer a beta-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) or an anticholinergic (ipratropium bromide 0.25-0.5 mg) 2
• For severe exacerbations or poor response to single agents, both may be administered together 2

Corticosteroid Therapy

• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time 2
• A 5-day course of prednisolone 30-40 mg/day (or 100 mg hydrocortisone if oral route not possible) is recommended 2

Antibiotic Therapy

• Prescribe antibiotics when patients present with increased dyspnea, increased sputum volume, and increased sputum purulence 2
• First-line antibiotics include amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid for 5-7 days 3, 2
• For more severe exacerbations, consider broader spectrum antibiotics such as newer cephalosporins, macrolides, or quinolone antibiotics 3

Management Based on Severity

Mild Exacerbations (Home Management)

• Provide antibiotics if indicated by symptoms 1
• Initiate, increase dose or frequency, or combine β₂-agonists and/or anticholinergics 1
• Encourage sputum clearance by coughing and fluid intake 1
• Consider home physiotherapy 1
• Avoid sedatives and hypnotics 1
• Instruct patient on symptoms and signs of worsening and action to take 1

Severe Exacerbations (Hospital Management)

• Evaluate severity, including life-threatening conditions 1
• Identify the cause of the exacerbation 1
• Provide controlled oxygenation 1
• Consider non-invasive ventilation (NIV) for patients with acute respiratory failure who have no absolute contraindications 2
• NIV improves gas exchange, reduces respiratory work and need for intubation, decreases hospital stay, and improves survival 2

Important Considerations and Pitfalls

• Avoid excessive oxygen administration in COPD patients due to risk of hypercapnic respiratory failure 3
• Do not routinely prescribe antimicrobials based on remote assessment; a face-to-face assessment is preferable if a person is potentially ill enough to require antimicrobials 1
• Short-course antibiotic therapy (5-7 days) is as effective as longer courses and reduces the risk of antimicrobial resistance 3
• When prescribing bronchodilators, ensure proper inhaler technique as this significantly impacts treatment effectiveness 3
• Monitor for paradoxical bronchospasm with inhaled medications, which can be life-threatening and requires immediate discontinuation of the medication 4
• Be cautious with beta-agonists in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias, hypertrophic obstructive cardiomyopathy, and hypertension 4