Infective Exacerbation of COPD

Target SpO₂ 88–92% via Venturi in known/suspected chronic type 2 failure — uncontrolled O₂ worsens hypercapnia. Bundle: air-driven nebs, prednisolone 30mg × 5 days, antibiotics if purulent. If pH <7.35 with PaCO₂ >6.5 after 1 hour of maximal therapy…

COPD Exacerbation Bundle (NICE NG115)

The pathway

1 · Controlled oxygen

Target SpO₂ 88–92%
Venturi 24–28% pending ABG
Never remove O₂ from a hypoxic patient — titrate

2 · ABG interpretation

pH is the key number
Raised HCO₃⁻/BE = chronic retainer
pH <7.35 + PaCO₂ >6.5 = acute decompensation

3 · Bronchodilators

Salbutamol 5mg + ipratropium 500mcg nebulised
DRIVE WITH AIR — supplement O₂ by nasal cannulae

4 · Steroids & antibiotics

Prednisolone 30mg OD × 5 days — no taper
Antibiotics if purulent sputum or consolidation (amoxicillin/doxycycline per local policy)

5 · NIV

pH <7.35 + PaCO₂ >6.5 after 1h optimal therapy
BiPAP: IPAP 12–15 / EPAP 4–5, titrate
Repeat ABG at 1 hour

6 · Ceiling of care

Document BEFORE starting NIV
NIV as bridge or ceiling?
Involve senior, ITU, patient and family

7 · Discharge bundle

Inhaler technique, rescue pack, self-management plan
Smoking cessation, pulmonary rehab, vaccinations
Oxygen alert card, follow-up 72h–2 weeks

Drugs

Drug	Dose	Route	Notes
Salbutamol	5mg NEB	NEB	Air-driven. Repeat as needed; watch potassium.
Ipratropium	500mcg NEB	NEB	Air-driven. QDS. Beware escaping mist in narrow-angle glaucoma.
Prednisolone	30mg OD × 5 days	PO	No taper needed for a 5-day course (NICE).
Amoxicillin / doxycycline	Per local policy	PO	Only if purulent sputum or consolidation.

When to escalate

pH <7.35 with PaCO₂ >6.5 after 1 hour of optimal therapy — NIV,pH <7.25 or deteriorating on NIV — ITU review,Exhaustion, drowsiness, rising CO₂ — anaesthetics,Ceiling of care undocumented — senior review before escalation

Reference: NICE NG115 COPD / BTS-ICS Guideline for Ventilatory Management of AHRF

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