A 72-year-old with known COPD is drowsy and breathless. ABG on 28% O2: pH 7.28, PaCO2 8.5, PaO2 7.2. Manage this patient.

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Accepted Answer

A–E assessment focusing on airway protection, respiratory effort, oxygenation, haemodynamics and consciousness. This ABG shows acute hypercapnic respiratory failure with acidosis, consistent with a COPD exacerbation. I would deliver controlled oxygen targeting saturations of 88–92% to avoid worsening hypercapnia. With pH below 7.35 and PaCO2 above 6 the patient meets criteria for non-invasive ventilation, so I would involve the respiratory team and initiate NIV in an appropriately monitored setting after checking for contraindications such as vomiting, reduced consciousness or haemodynamic instability, with a repeat ABG within one hour. Alongside NIV: nebulised salbutamol and ipratropium, oral or IV steroids, antibiotics if infective trigger suspected, and VTE prophylaxis. Importantly, I would discuss ceilings of care early — including whether invasive ventilation would be appropriate — involving the patient and family where possible.

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