Any person, 16 years and over, presenting with shortness of breath and has a history of chronic obstructive pulmonary disease (COPD).
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
If the patient has:
- asthma, switch to shortness of breath with a history of asthma protocol
- cardiac history, switch to shortness of breath with a history of cardiac disease protocol
- no known history, switch to shortness of breath protocol.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Onset of symptoms
- Triggers, including breathlessness on exertion
- Recent illness
- Pain assessment – PQRST
- Pre-hospital treatment
- Past admissions
- Medical and surgical history, including ICU or intubations
- Current medications, including home oxygen therapy
- Known allergies
- Recent contact with sick persons
- Smoking history
Signs and symptoms
- Respiratory distress
- Cough
- Sputum production, a change in colour and/or increased amount
- Haemoptysis
- Pale
- Diaphoretic
- Cool peripheries
- Chest pain
- Fever
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- Malignancy
- Previous intubation or ICU admission
- Unresponsive to prehospital management
Clinical
- Altered level of consciousness
- Confusion, agitation or irritability
- Tripod positioning
- Central cyanosis
- Talking in words only
- Severe respiratory distress
- Hypoventilation
- Exhaustion
Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
Position
Assessment | Intervention |
---|---|
General appearance/first impressions | Position of comfort Preferably semi-reclined or upright |
Airway
Assessment | Intervention |
---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
Assessment | Intervention |
---|---|
Respiratory rate and effort Oxygen saturations (SpO2) Auscultation chest (breath sounds) | Assist ventilation, as clinically indicated Apply oxygen to maintain SpO2 88–92% Caution in patients with known carbon dioxide retention Commence high flow nasal cannula if supported by care facility. If using high flow oxygen, aim to wean FiO2 to reduce risk of hypercapnia If ineffective respiratory effort, assess need for non-invasive ventilation – BiPAP or humidified high flow nasal cannula (if no contraindications) If wheeze present, select: Able to breathe via spacerGive:
Unable to breathe adequately via spacerGive with 8–10 L air via nebuliser:
|
Circulation
Assessment | Intervention |
---|---|
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm | Assess circulation Attach cardiac monitor and complete 12 lead ECG |
IVC and/or pathology | Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained |
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension | If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Disability
Assessment | Intervention |
---|---|
ACVPU | If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength |
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment as clinically indicated |
Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment |
Exposure
Assessment | Intervention |
---|---|
Temperature | Measure temperature |
Skin inspection, including posterior surfaces | Check and document any abnormalities |
Fluids
Assessment | Intervention |
---|---|
Hydration status: last ate, drank, bowels opened, passed urine or vomited | Commence fluid balance chart, as required |
Nausea and/or vomiting | If present, see nausea and/or vomiting section |
NBM | Consider clear fluids or NBM based on red flags and clinical severity |
Glucose
Assessment | Intervention |
---|---|
BGL | Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol |
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
Complete a respiratory focused assessment.
Precautions and notes
- In the absence of respiratory distress or any other signs of acute deterioration, SpO2 levels of 88–92% are acceptable in COPD patients. If SpO2 is less than 88%, or signs of respiratory distress are evident, higher flow oxygen should be used to resolve hypoxia.
- Do not withhold oxygen in severely dyspnoeic, hypoxic or critically unwell patients. The goal of oxygen therapy is to increase PaCO2 to over 60 mmHg and SaO2 over 90%. Altered level of consciousness is an important indicator of both, worsening hypoxia and hypercapnia.
- Aim to get an early venous blood gas (VBG) to measure PaCO2 level.
- If tolerated, delivery of short-acting beta agonists via MDI and spacer is the preferred method, and equally as effective as nebulisation.
Interventions and diagnostics
Specific treatment
If ineffective respiratory effort, consider non-invasive ventilation (NIV) where available and escalate as per local CERS protocol if required.
Analgesia
If pain score 1–6 (mild–moderate), give:
- paracetamol 1000 mg orally once only
- and/or ibuprofen 400 mg orally once only.
If severe pain present, give analgesia and escalate as per local CERS protocol.
Nausea and/or vomiting
If nausea and/or vomiting is present, give:
- metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
- or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
- or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only
Choice of antiemetic should be determined by cause of symptoms.
Radiology
- CXR
Pathology
- FBC, UEC
- ABG (if trained) or VBG
- Temp less than 35°C, or 38.5°C and over: take two sets of blood cultures from two separate sites
- Productive cough: consider sputum specimen for MC&S
Medications
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
Drug | Dose | Route | Frequency |
---|---|---|---|
Ibuprofen H, R | 400 mg | Oral | Pain score 1–10
Once only |
500 microg nebule | Inhalation via nebuliser | Give via nebuliser for patients who cannot use MDI and spacer Repeat every 20 minutes to a total of 3 doses | |
OR | |||
4 puffs | Inhalation via spacer | Repeat every 20 minutes to a total of 3 doses | |
Over 20 years: | Oral/IV/IM | Once only | |
4 mg Maximum dose 8 mg | Oral/IV/IM | Repeat once if required after 60 minutes | |
Oxygen | 2–15 L/min, device dependent | Inhalation | Continuous |
1000 mg | Oral | Pain score 1–10 Once only | |
5 mg | Oral | Once only | |
OR | |||
12.5 mg | IV/IM | Once only | |
5 mg nebule | Inhalation via nebuliser | Give via nebuliser for patients who cannot use MDI and spacer Repeat every 20 minutes to a total of 3 doses | |
OR | |||
12 puffs | Inhalation via spacer | Repeat every 20 minutes to a total of 3 doses | |
250 mL Maximum dose 1000 mL | IV/intraosseous | Bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- Therapeutic Guidelines. Chronic obstructive pulmonary disease (COPD) exacerbations Australia: Therapeutic Guidelines Limited; 2022 [cited 20 Feb 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?etgAccess=true&guidelinePage=Respiratory&topicfile=chronic-obstructive-pulmonary-disease-exacerbations&guidelinename=Respiratory§ionId=toc_d1e162#toc_d1e162
- Therapeutic Guidelines. Antiemetic drugs in adults. Australia: Therapeutic Guidelines Limited; 2022 [cited 15 Feb 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/topicTeaser?guidelinePage=Gastrointestinal&etgAccess=true#
- Stroller J. COPD exacerbations: Management: Emergency Department and Hospital Managment. UpToDate: Wolters Kluwer; 2022 [cited 20 Feb 2023]. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/copd-exacerbations-management
- Rochester C, Martinello R. Acute exacerbation of chronic obstructive pulmonary disease. USA: BMJ Best Practice; 2022 [cited 16 Feb 2023]. Available from: https://bestpractice.bmj.com/topics/en-us/8
- NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 13 Apr 2022]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- NSW Health. NSW Critical care tertiary referral networks and transfer of care (adults). Sydney: NSW Health; 2018 [cited 16 Feb 2023]. Available from: https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2018_011
- NSW Emergency Care Institute. Clinical tools: Respiratory. NSW: NSW Health; 2017 [cited 17 Feb 2023]. Available from: https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-tools/respiratory
- National Asthma Council. Managing asthma COPD overlap. National Asthma Council; 2022 [cited 17 Feb 2023]. Available from: https://www.asthmahandbook.org.au/clinical-issues/copd/managing-asthma-copd-overlap
- National Asthma Council. Australian Asthma Handbook. Australia: National Asthma Council; 2022 [cited 17 Feb 2023]. Available from: https://www.asthmahandbook.org.au/
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- Kuzniar T. Assessment of dyspnoea. USA: BMJ best practice; 2022 [cited 17 Feb 2023]. Available from: https://bestpractice.bmj.com/topics/en-gb/862
- Yang Ia, George J, McDonald CF, et al. The COPD-X plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease Version 2.66. Australia: Lung Foundation Australia; 2022 [cited 16 Feb 2023]. Available from: https://copdx.org.au/copd-x-plan/v2-66-04-2022/
- Global initiative for chronic obstructive lung disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.2018 [cited 16 Feb 2023]. Available from: https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf
- Bragg M. Non-invasive ventilation device settings: a brief guide. NSW: Emergency Care Institute; 2013 [cited 16 Feb 2023]. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/273555/niv-device-settings-endorsed-29-august-2013.pdf
- Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
Currency | Due for review: Jan 2026. Based on a regular review cycle. |
Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/shortness-of-breath-copd