Management of COPD Exacerbation

Oxygen Therapy Protocol

The British Thoracic Society recommends initial oxygen therapy to be limited to 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gas results are available 1, 2
The target oxygen saturation should be 88-92% for patients with COPD to avoid respiratory acidosis 2
If PaO2 is responding without pH deterioration, gradually increase oxygen concentration until PaO2 is above 7.5 kPa 1
If pH falls below 7.26, consider alternative ventilation strategies 1

Administer nebulized bronchodilators immediately on arrival and then at 4-6 hourly intervals, using either a beta-agonist or an anticholinergic, or both for severe exacerbations 1
Continue nebulized bronchodilators for 24-48 hours or until clinical improvement, then switch to metered dose inhalers or dry powder inhalers 3

The British Thoracic Society recommends a 7-14 day course of systemic corticosteroids, such as prednisolone 30 mg/day orally or 100 mg hydrocortisone intravenously 3

Prescribe antibiotics if there are signs of infection, with first-line antibiotics including amoxicillin or tetracycline, unless these were used with poor response prior to admission 1
For more severe exacerbations or poor response to first-line agents, consider broad-spectrum cephalosporins or newer macrolides 1

Perform chest radiograph to rule out pneumonia or other complications, and complete blood count, urea and electrolytes, and ECG within the first 24 hours 4
Consider diuretics if there is peripheral edema and raised jugular venous pressure, and consider prophylactic subcutaneous heparin for patients with acute-on-chronic respiratory failure 3

Repeat arterial blood gas measurements if the clinical situation deteriorates, and monitor oxygen saturation continuously with pulse oximetry 1
Record initial FEV1 and/or peak flow and start a serial peak flow chart, and consider non-invasive ventilation if the patient is hypercapnic and acidotic after 30 minutes of standard medical management 4, 5

Ensure the patient has adequate support to cope at home, understands the prescribed treatment and use of delivery devices, and has sufficient medication until the next opportunity for consultation 4

For a COPD patient with a 2-week deterioration, mild confusion, and respiratory acidosis, non-invasive positive pressure ventilation (NPPV) should be initiated immediately as the primary intervention, alongside controlled oxygen therapy and standard medical management, according to the European Respiratory Society guidelines 6
The presence of mild confusion is a concerning sign indicating impaired mental status from hypercapnic encephalopathy, which further supports the need for ventilatory assistance, as recommended by the British Thoracic Society 7, 8

When pH ≤7.35 with elevated PCO2 persists after 30 minutes of standard medical therapy, NIV should be initiated, as suggested by the European Respiratory Society 6
pH below 7.26 predicts poor outcomes, and this patient at 7.30 is approaching that critical threshold, according to the British Thoracic Society 7, 8

Controlled oxygen therapy targeting saturation 88-92% using 28% Venturi mask or 2 L/min nasal cannulae should be provided to prevent both hypoxia and oxygen-induced worsening of hypercapnia, as recommended by the British Thoracic Society 7, 8

Nebulized bronchodilators should be administered immediately, using combination therapy with beta-agonist and anticholinergic for severe exacerbations, as suggested by the British Thoracic Society 7, 8
Drive nebulizers with compressed air, not oxygen, when respiratory acidosis is present, according to the British Thoracic Society 7, 8

NIV is successful when ABGs and pH improve within 1-2 hours, dyspnea is relieved, and mental status improves, as recommended by the European Respiratory Society 6
Consider intubation if ABGs and pH worsen after 1-2 hours of NIV, or if there is no improvement in ABGs/pH after 4 hours of NIV, according to the European Respiratory Society 6