What is the step-by-step guideline for treating respiratory failure secondary to a severe Chronic Obstructive Pulmonary Disease (COPD) exacerbation in the emergency department?

From the Guidelines

Management of respiratory failure due to severe COPD exacerbation in the emergency department requires prompt assessment and intervention, starting with supplemental oxygen to maintain SpO2 between 88-92% and non-invasive positive pressure ventilation (NIPPV) as the first mode of ventilation to treat acute respiratory failure, as recommended by the most recent guidelines 1.

Initial Assessment and Intervention

Begin with rapid evaluation of airway, breathing, and circulation while simultaneously administering supplemental oxygen to maintain SpO2 between 88-92% (higher oxygen levels can suppress respiratory drive in COPD patients) 1. Obtain arterial blood gas analysis to assess pH, PaCO2, and PaO2.

Bronchodilation and Medication

For bronchodilation, administer nebulized albuterol 2.5-5mg and ipratropium bromide 0.5mg every 20 minutes for the first hour, then every 1-4 hours as needed, as recommended by the global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report 1. Give systemic corticosteroids such as methylprednisolone 125mg IV or prednisone 40-60mg orally, as they improve lung function and shorten recovery time and hospitalization duration 1. If signs of infection are present, start empiric antibiotics like azithromycin 500mg daily or amoxicillin-clavulanate 875/125mg twice daily, as they can shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration 1.

Ventilation and Monitoring

For patients with persistent hypoxemia or respiratory acidosis (pH<7.25 with elevated PaCO2), initiate non-invasive positive pressure ventilation (NIPPV) with initial settings of IPAP 10-12 cmH2O and EPAP 4-5 cmH2O, titrating as needed, as recommended by the official ERS/ATS clinical practice guidelines 1 and the global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report 1. Consider invasive mechanical ventilation if NIPPV fails, consciousness deteriorates, or severe hemodynamic instability develops. Maintain adequate hydration while avoiding fluid overload, and consider adjunctive treatments such as magnesium sulfate 2g IV over 20 minutes for additional bronchodilation. Throughout treatment, continuously monitor vital signs, oxygen saturation, and mental status, and prepare for ICU admission if the patient shows inadequate response to initial interventions.

Key Considerations

• Avoid excessive oxygen use in patients with COPD, as it can increase the risk of respiratory acidosis 1.
• Use a 24% Venturi mask at 2–3 L/min or nasal cannulae at 1–2 L/min or 28% Venturi mask at 4 L/min and aim for an oxygen saturation of 88–92% prior to availability of blood gas measurements 1.
• Patients with a significant likelihood of severe COPD or other illness that may cause hypercapnic respiratory failure should be triaged as very urgent on arrival in hospital emergency departments and blood gases should be measured on arrival in hospital 1.

From the FDA Drug Label

The use of ipratropium bromide inhalation solution as a single agent for the relief of bronchospasm in acute COPD exacerbation has not been adequately studied. Drugs with faster onset of action may be preferable as initial therapy in this situation.

The FDA drug label does not provide a step-by-step guideline for treating respiratory failure secondary to a severe Chronic Obstructive Pulmonary Disease (COPD) exacerbation in the emergency department.

From the Research

Step-by-Step Guideline for Treating Respiratory Failure Secondary to Severe COPD Exacerbation

• Assess the patient's symptoms, such as dyspnea, cough, and sputum production, and determine the severity of the exacerbation 2
• Provide targeted O2 therapy, titrated to an SpO2 of 88-92%, to improve outcomes 2
• Use arterial blood gases to assess gas exchange in patients with COPD exacerbation, and appreciate the limitations of arterial blood gas surrogates (pulse oximetry, capnography, transcutaneous monitoring, peripheral venous blood gases) 2
• Administer inhaled short-acting bronchodilators via nebulizer, pressurized metered-dose inhaler, or dry powder inhaler to help alleviate symptoms 2
• Consider using noninvasive ventilation (NIV) as standard therapy for patients with COPD exacerbation, as it has been shown to reduce mortality and improve outcomes 2, 3, 4, 5
• In mechanically ventilated patients with COPD, manage auto-PEEP by reducing airway resistance and decreasing minute ventilation, and address trigger asynchrony and cycle asynchrony to improve patient-ventilator interaction 2
• Extubate patients with COPD to NIV when possible, as it has been shown to reduce the risk of reintubation in hypercapnic patients 4
• Consider using high-flow nasal cannula in patients with COPD exacerbation, although the evidence for its use is limited 2, 4
• Provide care coordination and evidence-based practices to improve the effectiveness of care for patients with COPD exacerbation 2
• Consider the use of pharmacological strategies, such as bronchodilators, inhaled corticosteroids, and phosphodiesterase-4 inhibitors, to reduce exacerbation risk in patients with COPD 6