COPD Flare on the Vent

• Reach for NIV first when pH <7.35 with hypercapnia; it cuts intubation and mortality. Recheck the ABG at 1 h.
• Give salbutamol and ipratropium nebs plus prednisolone 40 mg ×5 d, reserving antibiotics for purulent sputum or increased dyspnoea.
• Deliver controlled O₂ 88–92% by Venturi, since uncontrolled O₂ worsens hypercapnia.
• Intubate when pH or mental state keeps failing on NIV, and ventilate with a prolonged expiratory time.
• GOLD 2026 (Rome proposal): acute hypercapnic respiratory failure = pH <7.35 with PaCO₂ >45 mmHg.

First-Line Workup and Medical Therapy of Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD)

• First evaluation: history and physical exam · triggers of the COPD exacerbation · more cough, sputum production, or dyspnea · previous hospitalizations or ICU admissions · tachypnea, tachycardia, accessory muscle use, wheezing · basic labs (complete blood cell count, basic metabolic panel) · chest radiography · arterial blood gas analysis
• Findings consistent with a COPD exacerbation?
• Treat the acute COPD exacerbation: oxygen by nasal cannula or face mask — titrate to SpO₂ 88–92%, avoiding overcorrection of hypoxemia that could precipitate hypercapnia
• Bronchodilators · corticosteroids · antibiotics (per local antibiogram)
• If mechanical ventilatory support needed → Pathway 12.2
• Treat the underlying medical condition

Mechanical Ventilation During Acute Exacerbations of Chronic Obstructive Pulmonary Disease

• Anything preventing noninvasive ventilation? (respiratory arrest or inability to protect the airway · hemodynamic instability · severe agitation / uncooperative patient · structural abnormality preventing mask fit · excessive secretions · active vomiting / aspiration risk)
• Proceed to endotracheal intubation
• Start BiPAP where endotracheal intubation can be performed if needed · titrate to SpO₂ 88–92%, avoiding hyperventilation that drops pCO₂ far below baseline
• Improving?
• Continue periodic BiPAP until respiratory status stabilizes
• Proceed to endotracheal intubation