How would you decide whether a COPD patient is appropriate for invasive ventilation?

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I would decide based on the likelihood of reversibility, baseline function, comorbidities and the patient's wishes, ideally guided by prior advance care planning. Reversibility: is there a treatable trigger such as infection, bronchospasm, fluid overload or PE, and how has the patient responded to NIV? Baseline function: pre-morbid exercise tolerance, frailty, previous ICU/IMV outcomes, long-term oxygen therapy and frequent admissions suggesting end-stage disease. Comorbidities: advanced cardiac disease, malignancy, neurological disease or multi-organ failure all worsen outcomes. Patient preferences: I would check for ReSPECT, DNACPR or LPA documentation and discuss honestly with the patient or family in a best-interests framework if capacity is lacking. I would involve the ICU consultant early and document the escalation plan clearly, communicating it to the MDT. The key is whether invasive ventilation offers a realistic path back to an acceptable quality of life, not just short-term survival.

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