What is the best initial approach for a patient with Do Not Intubate (DNI) status experiencing an exacerbation?

Management of DNI Patient with Exacerbation

For a patient with Do Not Intubate (DNI) status experiencing an exacerbation, provide non-invasive positive pressure ventilation (CPAP/BiPAP) as the primary ventilatory support, combined with aggressive medical management including controlled oxygen therapy, bronchodilators, and corticosteroids. 1

Initial Approach: Non-Invasive Ventilation is the Answer

• Non-invasive ventilation (NIV) is specifically designed for DNI patients and reduces mortality, complications, and length of stay without requiring intubation. 1, 2
• NIV achieves success rates of 80-85% in acute respiratory failure from exacerbations, making it the ideal intervention for patients who have declined intubation. 2
• Start NIV when pH <7.35 and pCO2 >6.5 kPa persist despite optimal medical therapy—this represents Grade A evidence. 1

Controlled Oxygen Therapy

• Target oxygen saturation of 88-92% in patients with COPD exacerbations and type 2 respiratory failure. 1, 2
• Uncontrolled high-flow oxygen directly increases mortality by worsening acidosis and hypercapnia—pre-hospital titrated oxygen reduces mortality by 58% compared to high-concentration oxygen. 1
• Obtain arterial blood gases immediately on arrival before any intervention, then repeat 30-60 minutes after initiating oxygen to assess for CO2 retention. 1, 2

Aggressive Medical Management

• Administer inhaled short-acting beta-agonists (salbutamol 5 mg or terbutaline 10 mg) via nebulizer every 20 minutes for 3 doses, then every 1-4 hours as needed. 3, 2
• Add ipratropium bromide 0.5 mg to nebulized bronchodilators for severe exacerbations, which reduces hospitalization rates. 3, 2
• Give systemic corticosteroids early—oral prednisone 30-60 mg daily or IV equivalent if oral intake not tolerated. 3, 2
• Consider antibiotics if sputum purulence is present or patient requires mechanical ventilation (invasive or non-invasive). 2

Comfort Measures Are Insufficient Alone

• Simply providing "comforting measurements" (option A) without active treatment would be inappropriate unless the patient has transitioned to comfort care only. 1
• DNI status means avoiding endotracheal intubation (option B), but does NOT mean withholding all aggressive interventions. 4
• Research shows 58% of patients with DNR/DNI orders actually want intubation for reversible conditions like angioedema, highlighting that DNI status requires careful interpretation in context. 4

Critical Pitfall to Avoid

The most dangerous error is assuming DNI means "do nothing"—these patients still require full medical management and non-invasive ventilatory support. Studies demonstrate that patients with DNR/DNI orders receive substandard care and have worse outcomes when healthcare providers incorrectly interpret code status as limiting all interventions. 5

• Nurses are significantly less likely to escalate care for DNI patients even when clinically indicated (P <0.001), representing a systemic bias that must be actively countered. 5
• DNI specifically prohibits endotracheal intubation only—it does not prohibit NIV, oxygen, bronchodilators, steroids, or ICU-level monitoring. 1, 4

Monitoring and Reassessment

• Repeat arterial blood gases 30-60 minutes after initiating NIV to ensure adequate oxygenation without worsening CO2 retention or acidosis. 1, 2
• Monitor for NIV failure indicators: worsening acidosis, increasing work of breathing, altered mental status, or patient intolerance. 1
• If NIV fails and the patient deteriorates with pH <7.25 and pCO2 >60 mmHg, this would typically indicate need for intubation—but given DNI status, transition to comfort-focused care becomes appropriate at this point. 1, 6