PLAB 2 COPD Exacerbation Station: Controlled Oxygen, Management & Free Practice

Hold these differentials in your head

Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.

• Acute exacerbation of COPD
  Increased breathlessness, cough and sputum (often more purulent) on a background of known COPD in a smoker or ex-smoker. The working diagnosis the station is testing.
• Community-acquired pneumonia
  Fever, focal crackles or consolidation on chest X-ray, raised CRP and white cell count. Often coexists with or triggers a COPD exacerbation.
• Pulmonary embolism
  Sudden breathlessness with pleuritic pain, tachycardia, sometimes haemoptysis, and thrombotic risk factors. Easy to miss against a noisy COPD background - keep it on the list.
• Acute heart failure
  Orthopnoea, basal crackles, raised JVP, ankle oedema and a cardiac history. Wheeze can mimic COPD; look for fluid overload and check the BNP / echo history.
• Pneumothorax
  Sudden unilateral pleuritic pain and breathlessness with reduced breath sounds and hyperresonance. COPD patients are at higher risk of spontaneous pneumothorax.
• Lung cancer
  In a long-term smoker with weight loss, haemoptysis or a persistent change in symptoms, keep malignancy in mind and safety-net for it.

Step-by-step approach

This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.

1. 1. Open the consultation - paced and empathic

   A breathless patient cannot answer long questions. Match their pace.

   • Wash hands, greet, introduce yourself with name and grade.
   • Confirm name and date of birth quickly.
   • Acknowledge the breathlessness and say you will keep questions short.
   • Start controlled oxygen as soon as the saturations finding allows.

2. 2. Take a focused, short-question history

   Short-answer questions, with time between them.

   • When did the breathing get worse, and over how long?
   • More sputum than usual? Has it changed colour (purulent)?
   • Any fever, chest pain or coughing up blood?
   • How many puffs of the reliever inhaler today?
   • Can they finish sentences? Wheeze?

3. 3. Critical COPD background - never skip these

   Previous severity and smoking are heavily graded.

   • Smoking history in pack-years - current or ex-smoker.
   • Baseline function - how far can they walk on a flat? Housebound?
   • Previous exacerbations and hospital admissions this year.
   • Previous ITU admission, intubation or non-invasive ventilation - ask explicitly.
   • Home oxygen or home nebulisers.
   • Inhaler regimen and compliance; vaccination status.

4. 4. Request examination and bedside findings

   Address the station for vitals, respiratory exam, ABG and a chest X-ray.

   • Vital signs - respiratory rate, oxygen saturation, heart rate, blood pressure, temperature.
   • Respiratory exam - air entry, wheeze, crackles, accessory muscle use, cyanosis.
   • Arterial blood gas - the key bedside test for type 2 respiratory failure and acidosis.
   • Chest X-ray - consolidation, pneumothorax, signs of heart failure.
   • ECG, bloods (FBC, U&Es, CRP), sputum culture, blood cultures if febrile.

5. 5. Give controlled oxygen - the safety-critical step

   Target 88-92% in COPD because of CO2-retention risk. This is the single most important management action.

   • If hypoxic, start controlled oxygen via a 24-28% Venturi mask.
   • Target saturations 88-92%, not 94-98%.
   • Recheck the ABG after starting oxygen to watch for a rising CO2 and falling pH.

6. 6. Nebulised bronchodilators

   First-line drug treatment, driven by air if CO2 retention is a concern.

   • Nebulised salbutamol 5 mg, repeated as needed.
   • Add nebulised ipratropium bromide 500 mcg.
   • Drive nebulisers with air (not oxygen) in patients at risk of CO2 retention.

7. 7. Steroids and antibiotics

   Per NICE: steroids for all exacerbations with significant breathlessness; antibiotics only if infection is likely.

   • Oral prednisolone 30 mg once daily for 5 days.
   • Antibiotics only if sputum is purulent or there are clinical signs of pneumonia.
   • Choose the antibiotic per local guidance (commonly amoxicillin, doxycycline or clarithromycin).

8. 8. Consider non-invasive ventilation and escalation

   Persistent respiratory acidosis despite treatment is the trigger for NIV.

   • Consider NIV (BiPAP) if the repeat ABG shows persistent respiratory acidosis (pH below 7.35 with a raised CO2).
   • Inform seniors and the medical registrar early.
   • Discuss escalation ceiling of care where appropriate.

9. 9. Address smoking and compliance without blame

   Graded interpersonal marks - counsel, do not shame.

   • Offer smoking-cessation support - it is the single most effective long-term intervention.
   • Review inhaler technique and compliance.
   • Offer flu and pneumococcal vaccination and a written self-management plan.

10. 10. Admit, safety-net and close

    Explain the plan in plain English and be explicit about warning signs.

    • Admit for treatment and monitoring where severity warrants.
    • Safety-net: alert staff immediately if breathing worsens, they become drowsy, or cannot speak.
    • Invite questions, check understanding, thank them and close.

Common pitfalls

• Starting high-flow 15 L oxygen reflexively - the COPD target is 88-92%, and uncontrolled oxygen risks CO2 retention. This is the classic safety-critical fail.
• Not requesting an arterial blood gas - it is the key test for type 2 respiratory failure.
• Forgetting to ask about previous ITU or NIV admissions - the strongest marker of severity.
• Not quantifying smoking in pack-years.
• Giving antibiotics to every exacerbation regardless of whether sputum is purulent.
• Forgetting steroids (prednisolone 30 mg for 5 days).
• Not recognising persistent respiratory acidosis as the trigger for NIV.
• Talking faster than the breathless patient can follow.

Frequently asked questions