Last Updated on February 23, 2019 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