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 inhaled salbutamol with ipratropium and prednisolone 40 mg orally once daily for 5 days. Use antibiotics for increased sputum purulence plus at least one of increased dyspnoea, fever or sputum volume; a prior positive sputum culture during an exacerbation; or a need for invasive/noninvasive mechanical ventilation. Choose treatment from prior cultures, local resistance and patient factors, usually for 5 days with reassessment.
• 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 tests: SpO2 and respiratory assessment, Arterial blood gas, Chest X-ray, 12-lead ECG, Full blood count, Sodium, potassium, bicarbonate, urea and creatinine.

Only if indicated: Respiratory culture, CT pulmonary angiography.

Repeat monitoring: Arterial blood gas.

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