How should an adult with an acute COPD exacerbation who is already receiving non‑invasive ventilation (BiPAP) be managed?

Management of COPD Exacerbation on BiPAP

Continue BiPAP with close monitoring and prepare for immediate intubation if the patient shows signs of NIV failure within 1–4 hours.

Immediate Assessment and Monitoring

Assess for absolute contraindications to continued NIV that mandate immediate intubation: respiratory arrest, cardiovascular instability (systolic BP < 90 mmHg), inability to protect the airway, copious or viscous secretions with high aspiration risk, or deteriorating mental status preventing cooperation with the mask. 1, 2

• Obtain arterial blood gases within 1–2 hours to evaluate pH and PaCO₂ response to BiPAP; worsening acidosis or rising PaCO₂ indicates NIV failure and requires immediate intubation. 1, 2

• Monitor continuously for respiratory rate, work of breathing, mental status, mask tolerance, and hemodynamic stability—deterioration in any parameter signals the need to escalate to invasive ventilation. 1, 2

BiPAP Settings and Oxygen Titration

• Optimize BiPAP settings if not already done: IPAP 12–15 cm H₂O, EPAP 4–5 cm H₂O, backup rate 12–15 breaths/min, targeting respiratory rate < 25 breaths/min and exhaled tidal volume ≥ 6–8 mL/kg ideal body weight. 1, 2

• Titrate supplemental oxygen through the BiPAP circuit to maintain SpO₂ 88–92%—avoid SpO₂ > 92% because over-oxygenation worsens hypercapnia and respiratory acidosis in chronic CO₂ retainers. 3, 1, 2, 4

Concurrent Medical Therapy

• Administer nebulized bronchodilators (salbutamol 2.5–5 mg and/or ipratropium 0.25–0.5 mg) every 2–4 hours for severe exacerbations; deliver via nebulizer with compressed air rather than oxygen to avoid exacerbating hypercapnia. 3, 1

• Give systemic corticosteroids (prednisolone 30–40 mg orally daily or hydrocortisone 100 mg IV if oral route not possible) for 10–14 days. 3, 1

• Initiate antibiotics if there is evidence of bacterial infection (increased sputum purulence and/or volume); first-line options include amoxicillin/clavulanate or respiratory fluoroquinolones (levofloxacin, moxifloxacin) based on local resistance patterns. 3

Criteria for Intubation (NIV Failure)

Proceed to immediate endotracheal intubation if any of the following occur:

• Worsening pH or PaCO₂ within 1–2 hours of optimal BiPAP, or no improvement in pH/PaCO₂ after 4–6 hours of NIV. 1, 2, 5, 6

• Severe respiratory acidosis (pH < 7.25) with marked hypercapnia (PaCO₂ > 60 mmHg / 8 kPa) despite BiPAP. 1, 2

• Deteriorating mental status (drowsiness, somnolence, inability to cooperate) or respiratory arrest. 1, 2

• Life-threatening hypoxemia (PaO₂/FiO₂ < 200 mmHg despite oxygen), severe tachypnea (respiratory rate > 35 breaths/min), or cardiovascular instability. 1, 2

• Copious or viscous secretions that cannot be cleared and increase aspiration risk. 1, 2

Setting of Care

• Manage in ICU or high-dependency unit with immediate intubation capability—a pH < 7.35 mandates this level of care, and general ward management is contraindicated. 1, 2

• Ensure experienced personnel are immediately available for rapid-sequence intubation if NIV fails; delayed intubation after NIV failure markedly increases mortality. 1, 2

Evidence Supporting Continued NIV

• Moderate-quality evidence shows that BiPAP reduces mortality (RR 0.54,95% CI 0.38–0.76; NNT 12) and need for intubation (RR 0.36,95% CI 0.28–0.46; NNT 5) compared with usual care alone in COPD exacerbations with respiratory acidosis. 5, 6

• NIV is effective across all severities of acidosis (pH 7.25–7.35), and attempting NIV first does not increase mortality when patients are monitored appropriately with rapid escalation to intubation if NIV fails. 1, 5

• Success rates of 80–85% have been demonstrated in randomized trials when NIV is applied with appropriate patient selection and monitoring. 2, 6

Critical Pitfalls to Avoid

• Do not delay intubation when NIV is clearly failing (worsening gas exchange, increasing respiratory distress, deteriorating mental status)—delayed intubation increases mortality. 1, 2

• Do not over-oxygenate—targeting SpO₂ > 92% exacerbates hypercapnia by suppressing respiratory drive and worsening V/Q mismatch in COPD patients. 3, 1, 2, 4

• Do not manage on a general ward—pH < 7.35 requires ICU/HDU level care with continuous monitoring and immediate intubation capability. 1, 2

• Do not assume drowsiness automatically precludes NIV—assess the patient's ability to cooperate and protect the airway, but if the patient cannot follow commands or is somnolent, intubate immediately. 1, 2

• Do not continue NIV beyond 4–6 hours without improvement—lack of pH/PaCO₂ improvement by this time predicts NIV failure and mandates intubation. 1, 2, 5