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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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