How do I determine the appropriate mode of mechanical ventilation for a patient with COPD exacerbation?

To determine the appropriate mode of mechanical ventilation for a patient experiencing a chronic obstructive pulmonary disease (COPD) exacerbation, first assess the severity of respiratory failure and the patient's overall clinical status. Non-invasive ventilation (NIV) is the treatment of choice for patients with persistent hypercapnic ventilatory failure despite optimal medical therapy during exacerbations of COPD. NIV should be delivered in a dedicated setting by trained staff experienced in its use, with a clear plan for escalation or ceilings of therapy in case of deterioration. Invasive ventilation is considered when NIV is contraindicated, not tolerated, or when the patient requires intensive care due to severe respiratory failure. When assessing suitability for invasive ventilation, consider the patient's functional status, body mass index (BMI), need for oxygen when stable, comorbidities, previous intensive care admissions, age, and FEV1; however, neither age nor FEV1 should be used in isolation. For patients who are slow to wean from invasive ventilation, consider transitioning to NIV. Regular monitoring with arterial blood gases is essential to guide ventilation management and assess recovery.