What is the most appropriate treatment for a 65-year-old woman with acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD), presenting with hyperthermia, hypertension, tachycardia, tachypnea, hypoxemia, and hypercapnia, on medications budesonide (corticosteroid)-formoterol (long-acting beta-agonist) inhaler and albuterol (short-acting beta-agonist)-ipratropium (anticholinergic)?

From the Guidelines

The most appropriate treatment for this 65-year-old woman with an acute COPD exacerbation is bilevel positive airway pressure (BiPAP). This patient presents with respiratory distress, hypoxemia (oxygen saturation 86% despite supplemental oxygen), and significant respiratory acidosis (pH 7.22, PCO2 75 mm Hg), indicating acute hypercapnic respiratory failure. BiPAP is specifically indicated in this scenario as it provides both inspiratory pressure support to reduce work of breathing and expiratory pressure to prevent airway collapse, which helps improve ventilation and reduce CO2 retention. Unlike continuous positive airway pressure (CPAP) which delivers constant pressure, BiPAP's dual pressure settings are particularly beneficial for COPD patients with hypercapnia. High-flow nasal cannula would not adequately address the severe hypercapnia, and immediate intubation would be premature as non-invasive ventilation should be attempted first in COPD exacerbations unless there are contraindications such as hemodynamic instability, inability to protect the airway, or severe acidemia that is rapidly worsening. According to the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1, non-invasive ventilation (NIV) should be the first mode of ventilation used in patients with COPD with acute respiratory failure who have no absolute contraindication. Additionally, the management of COPD exacerbations guideline by the European Respiratory Society/American Thoracic Society 1 also supports the use of NIV in patients hospitalized with a COPD exacerbation associated with acute or acute-on-chronic respiratory failure. The benefits of BiPAP in this context include reducing intubation rates, decreasing mortality, and shortening hospital stays in COPD patients with acute hypercapnic respiratory failure. Key points to consider in the management of this patient include:

• The use of short-acting inhaled β2-agonists, with or without short-acting anticholinergics, as the initial bronchodilators to treat an acute exacerbation 1
• The initiation of systemic corticosteroids to improve lung function and oxygenation, and shorten recovery time and hospitalization duration 1
• The consideration of antibiotics when indicated, to shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for COPD Exacerbation

The patient's condition, with a pH of 7.22, PCO2 of 75 mm Hg, and PO2 of 66 mm Hg, indicates severe respiratory acidosis and hypoxemia, suggesting the need for immediate intervention to support the respiratory system.

• Non-Invasive Ventilation (NIV): The study 2 supports the use of NIV in patients with hypercapnic acute respiratory failure and respiratory acidosis, which aligns with the patient's current condition.
• Bilevel Positive Airway Pressure (BiPAP): BiPAP is a form of NIV that can help reduce the work of breathing and improve gas exchange, making it a suitable option for this patient.
• Continuous Positive Airway Pressure (CPAP): While CPAP can be used in some cases of respiratory failure, it may not be as effective as BiPAP in patients with significant hypercapnia.
• High-Flow Nasal Cannula (HFNC): HFNC can provide a high flow of heated and humidified gas, which can help reduce the work of breathing and improve oxygenation. However, its effectiveness in severe hypercapnic respiratory failure is less clear.
• Intubation and Mechanical Ventilation: While this is a more invasive option, it may be necessary if the patient's condition does not improve with NIV or if there are signs of respiratory failure that require more aggressive support.

Most Appropriate Treatment

Given the patient's severe respiratory acidosis and hypoxemia, the most appropriate treatment would be A. Bilevel Positive Airway Pressure (BiPAP), as it can provide both inspiratory and expiratory support to help improve gas exchange and reduce the work of breathing. This is supported by the study 2, which highlights the effectiveness of NIV in patients with hypercapnic acute respiratory failure and respiratory acidosis.