Mr. Pradip: Drowsy Despite More Oxygen

• Give controlled oxygen, usually targeting SpO₂ 88–92% in suspected chronic CO₂ retainers while ABG is obtained and reassessed.
• Start frequent inhaled short-acting bronchodilators: salbutamol plus ipratropium via nebuliser or MDI/spacer; use oxygen-driven nebulisation cautiously in CO₂ retainers if compressed air is available.
• Give systemic corticosteroid, e.g. prednisolone 40 mg orally daily for about 5 days when oral route is feasible; use IV equivalent if not.
• Give antibiotics when there is increased sputum purulence with increased volume/dyspnoea, or when ventilatory support is required; tailor to local resistance and prior cultures.
• Start NIV promptly because he has acute respiratory acidosis (pH ≤7.35 with hypercapnia) and increased work of breathing, provided there is no immediate contraindication.

• Repeat ABG 1–2 hours after NIV initiation and after major changes in oxygen/ventilation.
• CBC, electrolytes, urea/creatinine, glucose; ECG; chest radiograph to exclude pneumonia, pneumothorax, pulmonary edema or other trigger.
• Sputum culture if severe, recurrent or ventilated; respiratory viral testing according to season/outbreak.
• Consider troponin/BNP/bedside echo if ACS or heart failure is plausible.

• Use a well-fitting oronasal mask, explain the process, minimise leaks and titrate inspiratory pressure to reduce respiratory rate/work and improve pH/CO₂.
• Assess NIV response clinically and by ABG: improving pH, falling PaCO₂, reduced RR and improved sensorium are reassuring.
• Correct reversible contributors: bronchospasm, retained secretions, sedative/opioid exposure, pneumothorax, fluid overload and infection.
• Avoid routine respiratory stimulants. Avoid excessive oxygen, which can worsen hypercapnia through V/Q effects and Haldane effect.

• After 90 minutes of NIV, pH improves to 7.29 and PaCO₂ to 68 mmHg; RR falls to 25/min and he is more alert.
• At 6 hours he remains stable but still needs NIV intermittently. Continue breaks for oral care, expectoration, hydration/nutrition as tolerated and pressure-area protection.
• If pH had continued to fall, consciousness worsened or haemodynamics became unstable, NIV failure should be declared early rather than delayed.

• Indications for intubation include respiratory arrest, inability to protect airway, severe agitation/obtundation, refractory hypoxaemia, worsening acidosis despite optimal NIV, shock, copious secretions or intolerance preventing effective NIV.
• If invasive ventilation is required, use a strategy that avoids dynamic hyperinflation: lower RR, adequate expiratory time, modest VT, high inspiratory flow and permissive hypercapnia if pH is acceptable.
• Watch for auto-PEEP and hypotension; external PEEP may help triggering in spontaneously breathing patients when set below intrinsic PEEP.

Acute exacerbation of COPD causing acute-on-chronic hypercapnic respiratory failure with respiratory acidosis.

• Continue bronchodilators, short steroid course, targeted antibiotics when indicated, controlled oxygen and NIV until acidosis/work of breathing resolve.
• Mobilise secretions, optimise long-acting inhaled therapy before discharge, assess inhaler technique and smoking cessation.
• Consider long-term oxygen only after stable-state reassessment; consider home NIV in selected patients with persistent chronic hypercapnia after recovery.

• GOLD guidance supports NIV as standard of care for hospitalised COPD exacerbation with acute respiratory failure; it reduces intubation and mortality.
• Target oxygen 88–92% until hypercapnia is excluded or stabilised.
• Early improvement in pH and respiratory rate predicts NIV success; worsening acidosis and mental status are warning signs.
• Mechanical ventilation must prioritise long expiratory time to prevent dynamic hyperinflation.