FFinalistSouthampton · 2027
Acute care
AKT · Acute care/Cardiac & respiratory

Acute exacerbation of COPD

Worsening chronic airflow limitation (often infective trigger)

Overview

An acute worsening of COPD with increased breathlessness, cough and sputum. The exam point is CONTROLLED oxygen via a Venturi mask in CO2 retainers (target 88–92%) and non-invasive ventilation for persistent respiratory acidosis.

Recognise

  • Increased dyspnoea, sputum volume/purulence, wheeze, in a known COPD patient
  • Often an infective or environmental trigger
  • Type 2 respiratory failure (CO2 retention) in chronic retainers

Red flags

  • Respiratory acidosis (pH <7.35 with high PaCO2) → NIV; falling consciousness/exhaustion → ICU

Differentials & how to tell them apart

Acute asthma (severe/life-threatening)younger, atopic, reversible; not a chronic CO2 retainer
Pneumoniafocal consolidation, fever, raised CRP
Acute pulmonary oedema (acute LVF)crackles, raised JVP, cardiac signs
Pulmonary embolismpleuritic pain, clear lungs, hypoxia with risk factors

Investigations

ABG (crucial — looks for type 2 failure/acidosis), CXR, ECG, FBC/CRP, sputum culture if purulent.

Management

Controlled O2 (88–92%) + nebs + steroids ± antibiotics; NIV for respiratory acidosis

  1. 1Controlled oxygen via Venturi (target 88–92%, recheck ABG), nebulised salbutamol + ipratropium, oral prednisolone, antibiotics if infective.Gate: Persisting respiratory acidosis (pH <7.35, raised PaCO2) despite optimal medical therapy → NIV (BiPAP)
  2. 2No improvement / falling pH or consciousness → consider intubation/ICU (ceiling-of-care decisions).
Controlled oxygen (Venturi, target 88–92%) — avoid uncontrolled high-flow O2 in retainers
Nebulised salbutamol + ipratropium — bronchodilators
Steroids (prednisolone) ± antibiotics — antibiotics if purulent sputum/infection
NIV (BiPAP) — persistent respiratory acidosis despite medical therapy

Key points

Do not over-oxygenate a CO2 retainer (risk of worsening hypercapnia) — titrate to 88–92%. NIV is the key escalation for respiratory acidosis.

Monitor & prognosis

Serial ABG (pH/CO2), SpO2 within target, conscious level, NIV response.

Good if reversible trigger treated; repeated admissions signal poor prognosis.

Source: NICE NG115 (COPD); BTS NIV guidance