Pulmonary Disorders II
Alternative to standard oxygen therapy or noninvasive positive pressure ventilation (GOLD 2024)
Indications for noninvasive MV include at least one of the following (GOLD 2024):
Respiratory acidosis (Paco2 45 mm Hg or greater and/or arterial pH 7.35 or less)
Severe dyspnea with clinical signs suggestive of respiratory muscle fatigue, increased work of
breathing, or both; use of accessory muscles; paradoxical motion of the abdomen; or retraction of
the intercostal spaces
Persistent hypoxemia despite supplemental oxygen
gas exchange, reduces work of breathing and need for MV, decreases hospitalization duration, and
improves survival (N Engl J Med 1995;333:817-22; Eur Respir J 2017;49:1600791).
Mechanical Ventilation: Indications for invasive MV (GOLD 2024)
Unable to tolerate or failure of noninvasive MV
Altered level of consciousness
Aspiration or vomiting
Hemodynamic instability despite fluid and vasopressors
Severe ventricular or supraventricular arrhythmias
Life-threatening hypoxemia and inability to tolerate noninvasive ventilation
Inability to manage respiratory secretions
Inhaled SABAs (nebulized or MDI) with or without a short-acting anticholinergic are preferred for
bronchodilation in ECOPD.
regimen. If patients have not yet started these agents, initiate long-acting agents as soon as patient is
stable and prior to discharge.
Currently, evidence is lacking regarding a mode of delivery when comparing nebulizers with MDIs
during ECOPD, though continuous nebulization is not recommended (GOLD 2024; Cochrane Database
Syst Rev 2016;8:CD011826).
Treatments NOT recommended: Methylxanthines (theophylline and aminophylline) because of
significant adverse effects
Corticosteroids shorten recovery time, improve lung function (FEV1), improve oxygenation, and
decrease the risk of early relapse, treatment failure, and length of hospitalization (GOLD 2024; N Engl
J Med 1999;340:1941-7; Chest 2001;119:726-30). Prednisone 40 mg daily or equivalent (preferably oral)
for 5 days may shorten recovery time in acute ECOPD. If oral administration is not an option, equivalent
doses of intravenous methylprednisolone or nebulized budesonide can be administered (GOLD 2024).