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COPD exacerbation with acute hypercapnic respiratory failure — SCE Acute Medicine MCQ

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EasyAcute Respiratory FailureCOPD exacerbation with acute hypercapnic respiratory failureSCE Acute Medicine

A 68-year-old man with severe COPD is admitted with two days of worsening dyspnoea and purulent sputum. He is drowsy but rousable, RR 30, SpO2 86% on 28% Venturi oxygen, and has widespread wheeze. ABG on 28% oxygen shows pH 7.28, PaCO2 9.1 kPa, PaO2 7.8 kPa, HCO3 33 mmol/L. He has already received nebulised bronchodilators, controlled oxygen, corticosteroid and antibiotics. What is the most appropriate next step in management?

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Correct answer: B — Start bilevel non-invasive ventilation

The persisting acidosis with hypercapnia after optimal initial treatment is the key indication for bilevel NIV in a COPD exacerbation. Increasing oxygen concentration risks worsening CO2 retention and does not address ventilatory failure. Aminophylline is a later adjunct with toxicity risk, while bronchoscopy is not indicated for routine sputum clearance. The teaching point is to reassess with ABG after initial therapy and escalate early when pH remains below 7.35 with raised PaCO2.

Reference: NICE NG115, BTS/ICS acute hypercapnic respiratory failure guideline