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Table 6 Management of Acute Respiratory Failure with COPD
1.	Correct Physiologic Abnormalities
	A.	Correct life-threatening hypoxemia:
		1.	Usually requires only small increase in FIO2 (1 to 2 L/min by nasal prongs).
		2.	Infiltrate or pulmonary edema suggests the presence of a shunt, and a higher FIO2 may be required.
		3.	Usually the therapeutic goal is a PaO2 of 55 to 65 mm Hg (associated with nearly complete oxygen saturation of hemoglobin).
		4.	Observe for signs of CO2 retention and check arterial blood gases after increments in FIO2 .
	B.	Correct life-threatening respiratory acidosis:
		1.	Usually is less urgent than correcting hypoxemia.
		2.	Usually is accomplished with therapy to improve airflow and to remove secretions.
		3.	Decision to use mechanical ventilation depends more on clinical status (especially mental status) than level of pH or PCO2.
		4.	Bicarbonate therapy is rarely indicated.
2.	Treat Airflow Obstruction
	A.	Treatment aimed at bronchodilation and control of inflammation:
		1.	First-line: Use inhaled ipratropium and beta-agonist; intravenous corticosteroids.
		2.	Second-line: Use theophylline.
	B.	Treatment aimed at improving secretion removal:
			Use hydration, chest percussion, inhaled heated moisture as indicated.
3.	Treat Precipitating Events As Indicated (e.g., Acute Purulent Bronchitis, Pneumonia, Congestive Heart Failure)
4.	Prevent Complications
	A.	Cardiac dysrhythmias: maintain oxygenation and normalize electrolyte values; monitor level of theophylline, if used.
	B.	Pulmonary thromboembolism: use subcutaneous heparin for prophylaxis, if not contraindicated.
	C.	Treat gastrointestinal complications. Prophylaxis of gastrointestinal bleeding: sucralfate, Nasogastric suctioning, if aerophagia is a problem.
	D.	Nosocomial infection: use sucralfate for prophylaxis of gastrointestinal bleeding.

1.

Correct Physiologic Abnormalities

A.

Correct life-threatening hypoxemia:

1.

Usually requires only small increase in FIO2 (1 to 2 L/min by nasal prongs).

2.

Infiltrate or pulmonary edema suggests the presence of a shunt, and a higher FIO2 may be required.

3.

Usually the therapeutic goal is a PaO2 of 55 to 65 mm Hg (associated with nearly complete oxygen saturation of hemoglobin).

4.

Observe for signs of CO2 retention and check arterial blood gases after increments in FIO2 .

B.

Correct life-threatening respiratory acidosis:

1.

Usually is less urgent than correcting hypoxemia.

2.

Usually is accomplished with therapy to improve airflow and to remove secretions.

3.

Decision to use mechanical ventilation depends more on clinical status (especially mental status) than level of pH or PCO2.

4.

Bicarbonate therapy is rarely indicated.

2.

Treat Airflow Obstruction

A.

Treatment aimed at bronchodilation and control of inflammation:

1.

First-line: Use inhaled ipratropium and beta-agonist; intravenous corticosteroids.

2.

Second-line: Use theophylline.

B.

Treatment aimed at improving secretion removal:

Use hydration, chest percussion, inhaled heated moisture as indicated.

3.

Treat Precipitating Events As Indicated (e.g., Acute Purulent Bronchitis, Pneumonia, Congestive Heart Failure)

4.

Prevent Complications

A.

Cardiac dysrhythmias: maintain oxygenation and normalize electrolyte values; monitor level of theophylline, if used.

B.

Pulmonary thromboembolism: use subcutaneous heparin for prophylaxis, if not contraindicated.

C.

Treat gastrointestinal complications. Prophylaxis of gastrointestinal bleeding: sucralfate, Nasogastric suctioning, if aerophagia is a problem.

D.

Nosocomial infection: use sucralfate for prophylaxis of gastrointestinal bleeding.