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Pulmonary · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Ex-smoker with COPD, 3 days of more breathlessness and purulent sputum; SpO₂ 84% on air; ABG pH 7.30, PaCO₂ 62 mmHg, PaO₂ 50
Red flags pH <7.35 with rising CO₂ Drowsiness Haemodynamic instability New AF or chest pain Differential diagnosis Pneumonia Heart failure Pulmonary embolism Pneumothorax TB (India) When to admit, call ICU or discharge Admit: Acidosis, hypoxia not correctable at home, severe breathlessness, comorbidity, poor home supportICU: NIV failure, pH <7.25, ↓GCS, instabilityIntubate: NIV failure or contraindication, respiratory arrest, severe acidosis with drowsinessVentilate: Low rate, long expiration, avoid rapid CO₂ correctionKey points Only smoking cessation and long-term O₂ (PaO₂ ≤55 mmHg or SpO₂ ≤88%) reduce COPD mortality. Readmission within 30 days is common — the discharge bundle and rehab reduce it. India: biomass smoke exposure causes COPD in non-smoking women. Never Give uncontrolled high-flow O₂ to a CO₂-retaining COPD patient Delay NIV in acidotic hypercapnia Give antibiotics without purulence, raised volume/breathlessness or ventilation Continue oral steroids beyond 5 days routinely Common mistakes Over-oxygenation Late NIV Missing PE or pneumonia No discharge bundle Disposition and follow-up Ward with NIV capability; ICU if NIV fails. Pulmonary rehab and review at 4–6 weeks.
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