COPD exacerbation and respiratory failure

Manage now— do this, in order

• Sit upright and give controlled oxygen by Venturi mask at 24% or 28%, targeting SaO₂ 88–92% or PaO₂ above 8 kPa without worsening acidosis; start at 24% and titrate by measurement, repeating the gas after each change — most need no more than 24–28%. If peri-arrest, unconscious or the saturation unrecordable, give high-concentration oxygen by reservoir mask at 15 L/min and correct once a gas is available — hypoxaemia kills in minutes, hypercapnia in hours.
• Nebulised salbutamol 5 mg with ipratropium bromide 500 micrograms in the same chamber, repeated 4–6 hourly — every 20–30 minutes in the first hour if severe. Drive the nebuliser with compressed air, giving oxygen concurrently by nasal cannula at 1–2 L/min; if only oxygen is available, keep the run short and restore the controlled-oxygen device immediately.
• Oral prednisolone 30 mg daily for 5 days — no taper needed for a five-day course. The bronchodilator and the corticosteroid do not wait for the blood gas or the radiograph.
• Antibiotic where there is purulent sputum, increased sputum volume, fever, radiographic consolidation, or raised CRP or white cells — and record the reason: amoxicillin 500 mg orally three times daily for 5–7 days first line; co-amoxiclav 625 mg 8-hourly (1.2 g IV 8-hourly if unable to swallow); doxycycline 200 mg day 1 then 100 mg daily in penicillin allergy (avoid in pregnancy); clarithromycin 500 mg twice daily; or azithromycin 500 mg daily for 3 days.Doctor / Nurse
• Reassess at 30–60 minutes and repeat the gas. pH ≥ 7.35 with PaCO₂ ≤ 6.5 kPa: continue controlled oxygen, nebulisers, corticosteroid and treat the precipitant. pH < 7.35 with PaCO₂ > 6.5 kPa: the next hour is active treatment, not observation — right oxygen concentration, repeated bronchodilators, steroid and antibiotic in, patient upright, secretions cleared, every sedating drug stopped.Not available at your setup — Arterial blood gas.
• If the acidosis has not corrected after that hour, start non-invasive ventilation (pH < 7.35, PaCO₂ > 6.5 kPa): begin IPAP 12–15 cmH₂O and EPAP 4–5 cmH₂O, increasing IPAP against tolerance, chest expansion and the repeat gas, entrained oxygen to the same 88–92% target. NIV needs a patient who is conscious, cooperative, able to protect the airway and able to expectorate. The gas one hour after NIV begins is the decisive measurement.Doctor / NurseNot available at your setup — Mechanical ventilator. No NIV: continue maximal medical therapy and transfer urgently — pH below 7.35 that will not correct is the referral trigger.
• Never sedate a hypercapnic, agitated COPD patient — benzodiazepines, opioids and sedating anti-emetics reduce respiratory drive; agitation is hypoxaemia and hypercapnia until proved otherwise.
• Supportive care: furosemide 20–40 mg IV for peripheral oedema (monitor potassium, urine output, renal function), frequent physiotherapy with or without pharyngeal suction, correct hypokalaemia, hypophosphataemia, hypomagnesaemia, anaemia, hyperglycaemia and dehydration, VTE prophylaxis, and do not stop maintenance inhalers.Doctor / Nurse
• Escalate to invasive ventilation for deteriorating acidosis despite optimal NIV, an intolerable interface, an unprotected airway, severe distress despite maximal therapy (respiratory rate > 40/min, inability to speak, exhaustion), declining consciousness, PaCO₂ rising above 8 kPa (60 mmHg), or PaO₂ below 8 kPa despite oxygen. Children: COPD does not occur — the 88–92% target does not apply; give oxygen freely to SpO₂ 94–98%.Doctor / NurseNot available at your setup — Endotracheal intubation kit, Mechanical ventilator.