COPD

Last Updated on by FRCEM Intermediate

Treatment 

  • Controlled oxygen therapy to maintain SaO2 88-92%
  • Nebulised salbutamol 2.5-5 mg
  • Nebulised Ipratropium 500 micrograms
  • Prednisolone 30 mg
  • Antibiotic agent (when indicated)

Indications for NIV include:

  • pH <7.35 and a PaCO2 >6kPa or 45mmHg
  • Severe dyspnea with clinical signs suggestive of muscle fatigue, increases work of breathing, such as use of respiratory muscles, paradoxical motion of the abdomen, or retraction of the intercostal spaces.
  • Persistent hypoxaemia, despite supplemental oxygen therapy

Commencing NIV

  • An initial Inspiratory Positive Airway Pressure (IPAP) of 10 cm H20 and Expiratory Positive Airway Pressure (EPAP) of 4-5 cm of water should be used.
  • This should be increased rapidly at a rate of approximately 5 cm of water every 10 minutes to a target of 20 cm H2O (IPAP), or patient unable to tolerate further, or therapeutic response achieved

Inclusion criteria for NIV

  • Primary diagnosis of COPD exacerbation
  • Able to protect airway
  • Conscious and cooperative
  • Patients wishes considered and potential quality of life acceptable for patient

Exclusion criteria for NIV:

  • Life threatening hypoxaemia
  • Severe co-morbidity
  • Confusion/agitation/cognitive impairment
  • Facial burns/trauma/recent facial or upper airway surgery
  • Vomiting
  • Fixed upper airway obstruction
  • Undrained pneumothorax
  • Upper gastrointestinal surgery
  • Inability to protect the airway
  • Copious respiratory secretions
  • Haemodynamically unstable requiring inotropes/vasopressors (unless in critical care unit)
  • Patient moribund
  • Bowel obstruction
  • Patient declines treatment

Indications Invasive Mechanical Ventilation

  • Inability to tolerate NIV or NIV failure
  • Status post respiratory or cardiac arrest
  • Diminished consciousness, psychomotor agitation inadequately controlled by sedation
  • Massive aspiration or persistent vomiting
  • Persistent inability to remove respiratory secretions
  • Severe ventricular or supraventricular arrhythmias
  • Severe haemodynamic instability unresponsive to fluid and vasopressors
  • Life threatening hypoxaemia in patients unable to tolerate NIV

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