What is the management plan for Chronic Obstructive Pulmonary Disease (COPD) type 2 respiratory failure?

Management of COPD Type 2 Respiratory Failure

Non-invasive ventilation (NIV) is the first-line ventilatory support for acute hypercapnic respiratory failure in COPD and should be initiated when pH <7.35, PaCO2 ≥6.5 kPa, and respiratory rate >23 breaths/min persist after one hour of optimal medical therapy. 1

Acute Management

Initial Assessment and Oxygen Therapy

• Obtain arterial blood gas measurement immediately to diagnose and quantify the severity of acute hypercapnic respiratory failure before starting treatment 1
• Initiate controlled oxygen therapy targeting saturation of 88-92% to reduce mortality and prevent worsening hypercapnic respiratory failure 1
• Start oxygen at low doses: 24% by Venturi mask or 1-2 L/min by nasal cannulae 1
• Monitor arterial blood gases regularly and adjust oxygen to maintain target saturation without elevating PaCO2 by >1.3 kPa or lowering pH to <7.25 1
• High inspired oxygen concentrations can worsen ventilation/perfusion mismatching and induce hypoventilation, leading to severe acidosis 2

Pharmacological Interventions

• Administer nebulized bronchodilators immediately: short-acting β2-agonists with or without short-acting anticholinergics 3, 1
• Consider combination therapy with both bronchodilator types for severe exacerbations or poor response to single agents 1
• Initiate systemic corticosteroids (prednisolone 30 mg/day for 7-14 days) as they improve lung function, oxygenation, and shorten recovery time 3, 1
• Prescribe antibiotics when indicated (purulent sputum, increased sputum volume) as they shorten recovery time and reduce risk of early relapse 3
• Avoid methylxanthines due to side effects without clear benefit 3

Non-Invasive Ventilation (NIV)

NIV should be initiated when pH <7.35, PaCO2 ≥6.5 kPa, and respiratory rate >23 breaths/min persist after one hour of optimal medical therapy including controlled oxygen and bronchodilators. 1

• Consider NIV for patients with PaCO2 between 6.0 and 6.5 kPa even if pH is not severely acidotic 1
• NIV reduces the need for invasive mechanical ventilation, shortens hospital length of stay, and is most effective when used earlier rather than later 3
• Document an individualized plan at treatment initiation regarding measures if NIV fails 1
• Confused patients and those with large volume of secretions are less likely to respond well to NIV 3

Invasive Mechanical Ventilation

Consider invasive intermittent positive pressure ventilation (IPPV) when pH <7.26 with rising PaCO2 despite NIV and controlled oxygen therapy. 1

Factors favoring IPPV use include: 3

• First episode of respiratory failure
• Demonstrable remedial reason for current decline (e.g., pneumonia, drug overdosage)
• Acceptable quality of life or habitual level of activity prior to admission

Factors discouraging IPPV use include: 3

• Previously documented severe COPD unresponsive to maximal therapy

• Poor baseline quality of life (e.g., housebound despite maximal therapy)

• Severe co-morbidities (e.g., pulmonary edema, neoplasia)

• Neither age alone nor PaCO2 level are good predictors of outcome; pH >7.26 is a better predictor of survival 3

• Misconceptions about difficulty weaning should not preclude intubation; mean survival of patients who were hypercapnic on admission but later became normocapnic was 2.9 years 3

Chronic/Stable Management

Long-Term Oxygen Therapy (LTOT)

LTOT for at least 15 hours/day improves survival in patients with severe resting hypoxemia. 3, 1

LTOT criteria include: 3, 1

• PaO2 ≤7.3 kPa (55 mm Hg) or SaO2 ≤88%, with or without hypercapnia, confirmed twice over a 3-week period

• PaO2 between 7.3-8.0 kPa (55-60 mm Hg) or SaO2 of 88% if evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit >55%)

• LTOT does not benefit patients with stable COPD and only moderate desaturation during rest or exercise 3

• Supplemental oxygen reduced mortality among symptomatic patients with resting hypoxia (relative risk 0.61,95% CI 0.46 to 0.82) 3

Long-Term Non-Invasive Ventilation

Consider long-term NIV in patients with pronounced daytime hypercapnia (PaCO2 >7 kPa) and recent hospitalization for acute respiratory failure. 3, 4

• Long-term NIV in stable COPD reduces PaCO2 at 3 months (adjusted mean difference -0.61 kPa) and 12 months (adjusted mean difference -0.42 kPa) 4
• NIV likely reduces all-cause mortality in stable hypercapnic COPD (adjusted hazard ratio 0.75,95% CI 0.58 to 0.97) 4
• In post-exacerbation COPD with persistent hypercapnia, NIV may prolong admission-free survival (adjusted hazard ratio 0.71,95% CI 0.54 to 0.94) 4
• High-intensity NIV settings targeting normocapnia may provide greater benefit than conventional settings 5, 6

Maintenance Pharmacotherapy

Initiate long-acting bronchodilators (LAMA and/or LABA) as soon as possible before hospital discharge. 3

• Long-acting inhaled therapies reduce exacerbations by 13-25% compared to placebo 3
• For patients with high symptom burden and risk of exacerbations, combination LAMA + LABA is preferred 3
• Add inhaled corticosteroids (ICS) to long-acting bronchodilators for patients with repeated exacerbations and FEV1 <50% predicted 3
• ICS + LABA reduced deaths compared to placebo (relative risk 0.82,95% CI 0.69 to 0.98) with absolute reductions of 1% or less 3
• ICS monotherapy should NOT be used in COPD management 3

Pulmonary Rehabilitation

• Pulmonary rehabilitation improves health status, dyspnea, and quality of life in patients with COPD 3, 1
• Patients with high symptom burden and risk of exacerbations should participate in a full rehabilitation program 3
• Pulmonary rehabilitation can reduce readmissions and mortality when initiated after a recent exacerbation (<4 weeks from hospitalization) 3
• Initiating pulmonary rehabilitation before hospital discharge may compromise survival 3

Monitoring and Follow-Up

• Check arterial blood gas tensions on room air before discharge in patients presenting with hypercapnic respiratory failure to guide need for LTOT 3, 1
• Record FEV1 before hospital discharge 3
• Monitor peak flow twice daily until clinically stable 3
• Assess for reversible causes contributing to respiratory failure 1
• Re-evaluate need for long-term oxygen therapy after stabilization 1

Additional Interventions

• Influenza vaccination reduces serious illness, death, and exacerbations 3
• Pneumococcal vaccinations (PCV13 and PPSV23) are recommended for all patients ≥65 years and younger patients with significant comorbidities 3
• Nutritional supplementation is recommended for malnourished patients with COPD 3
• Consider roflumilast for patients with FEV1 <50% predicted and chronic bronchitis with frequent exacerbations 3
• Consider prophylactic macrolide therapy in former smokers with frequent exacerbations 3