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COPD exacerbation
Controlled oxygen, an early gas, and NIV for those who need it. Give oxygen to a target of 88–92%, check an ABG, start bronchodilators and steroids, treat infection, and know the NIV criteria. Look for the mimics: pneumothorax, PE, heart failure and pneumonia. Built for revision, not live patient decisions.
Settle them, and check the basics
controlled oxygenRed flags — what each should make you think
Too much oxygen harms patients with COPD who retain CO₂. Use a Venturi mask (24% or 28%) aiming for 88–92% until you have a gas. But never withhold oxygen from a hypoxic patient: hypoxia kills faster than hypercapnia.
First actions
- O₂Controlled oxygen
- ABGArterial gas
- β₂Nebulised bronchodilators
- StPrednisolone 30 mg
- ℞Antibiotics if indicated
- NIVNIV if criteria met
Understand the patient
severity + the NIV decisionNIV criteria (BTS/ICS)
- Acute hypercapnic respiratory failure: pH below 7.35 and PaCO₂ above 6.5 kPa persisting despite optimal medical therapy (about 1 h)
- Start in a monitored setting with a clear plan: what to do if it fails (ceiling of care, intubation or not)
- pH below 7.25 — higher risk of failure; consider HDU/ITU
- Recheck ABG at 1–2 h, then 4–6 h
Contraindications to consider: undrained pneumothorax, facial trauma, vomiting/unable to protect airway, copious secretions, fixed upper airway obstruction.
Severity and context
- Usual exercise tolerance, MRC dyspnoea score, home oxygen, previous NIV/ITU
- Escalation decisions and patient wishes — discuss early
- DECAF score helps predict in-hospital mortality (Dyspnoea, Eosinopenia, Consolidation, Acidaemia, AF)
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Drowsiness, flap, bounding pulses, headache; pH below 7.35, PaCO₂ above 6.5.
ABG.
Controlled oxygen, maximal medical therapy, then NIV. Discuss escalation and ceiling of care early.
Sudden breathlessness or pleuritic pain; bullae make it easy to miss.
CXR (CT if unclear). Don't start NIV with an untreated pneumothorax.
Secondary pneumothorax often needs a chest drain. See the pneumothorax page.
Fever, focal signs, consolidation on CXR.
CXR, CRP.
Treat as pneumonia (CURB-65) in addition to the exacerbation.
No infective trigger, pleuritic pain, clear CXR (PE); oedema, crackles, raised BNP (HF).
CTPA, BNP, echo.
Treat the actual cause.
Investigate — what to order, when, and what it tells you
test with a question in mindABG
CXR
ECG
Bloods
How the plan comes together
disposition · handoverhome / early supported discharge
Mild exacerbation, normal gas, good function and support, able to manage at home. Rescue pack, inhaler check, pulmonary rehab referral, smoking cessation.
admit / respiratory HDU
Acidosis, NIV, hypoxia, new or worsening cor pulmonale, confusion, poor social support.
Hand over: gas trend, oxygen target, NIV settings, ceiling of care.
Target 88–92%, get a gas, and give NIV early to those who meet the criteria. Write the escalation plan before 3 am, not at 3 am. Nicely done getting here.
Clerking template
copy or downloadCOPD exacerbation — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for an acute COPD exacerbation?
- pH below 7.35 with PaCO₂ above 6.5 — think hypercapnic failure — NIV
- pH below 7.25 / drowsy — think severe — senior/ITU
- Sudden pleuritic pain, absent sounds — think pneumothorax
- Focal consolidation — think pneumonia
- Crackles, oedema, raised JVP — think heart failure
- SpO₂ above 92% on high-flow O₂ — think too much oxygen — CO₂ risk
What is the initial management of an acute COPD exacerbation?
- Controlled oxygen — 24–28% Venturi mask, target 88–92%
- Arterial gas — within 1 h, and 30–60 min after any oxygen change
- Nebulised bronchodilators — salbutamol and ipratropium, air-driven (supplement oxygen via nasal cannula)
- Prednisolone 30 mg — daily for 5 days
- Antibiotics if indicated — purulent sputum or pneumonia; per local policy
- NIV if criteria met — see below
Always alongside senior support and your local guideline.
What diagnoses must you not miss in an acute COPD exacerbation?
- Hypercapnic respiratory failure — acidotic · drowsy
- Pneumothorax — sudden deterioration
- Pneumonia — consolidation
- PE / heart failure (mimics) — not every breathless COPD patient is exacerbating
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for an acute COPD exacerbation?
- ABG — Hypercapnia, acidosis, compensation (chronic vs acute).
- CXR — Pneumothorax, consolidation, effusion, oedema.
- ECG — AF, ischaemia, right heart strain.
- Bloods — FBC (eosinophils), U&E, CRP, theophylline level if on it.
Admit or discharge: how is the plan decided for an acute COPD exacerbation?
- Home / early supported discharge — Mild exacerbation, normal gas, good function and support, able to manage at home. Rescue pack, inhaler check, pulmonary rehab referral, smoking cessation.
- Admit / respiratory hdu — Acidosis, NIV, hypoxia, new or worsening cor pulmonale, confusion, poor social support.
Is there a clerking template for an acute COPD exacerbation?
Yes — there is a free clerking template for an acute COPD exacerbation on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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