A 70-year-old man with severe COPD (FEV1 28% predicted), chronic hypercapnia (PaCO2 56 mmHg), and pulmonary hypertension presents with acute exacerbation. ABG on 2 L/min oxygen: pH 7.32, PaCO2 68 mmHg, PaO2 72 mmHg, HCO3 34 mEq/L. He is drowsy but rousable. What is the most appropriate initial respiratory support?
- A High-flow nasal cannula
- B Immediate endotracheal intubation
- C Non-invasive ventilation (BiPAP) ✓
- D Continue current oxygen and reassess in 2 hours
Correct answer: C. Non-invasive ventilation (BiPAP)
Explanation
Non-invasive ventilation is the standard of care for acute hypercapnic respiratory failure in COPD exacerbation with respiratory acidosis (pH 7.25-7.35). It reduces intubation rate and mortality. Intubation is reserved for patients with pH <7.25, impaired consciousness, or NIV failure. High-flow nasal cannula is not first-line for hypercapnic failure.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.