Controlled oxygen, bronchodilators, steroids, and antibiotics if infected
Expansion
OSHA:
- O - Oxygen, controlled, targeting 88 to 92 per cent with a Venturi mask until blood gases are known
- S - Salbutamol and ipratropium nebulisers, driven by air with nasal oxygen alongside, not driven by oxygen
- H - Hydrocortisone, or oral prednisolone 30 mg for 5 days
- A - Antibiotics, only if the sputum is purulent or there is clinical or radiological evidence of pneumonia
Then reassess with an arterial blood gas.
Non-invasive ventilation is indicated for persistent respiratory acidosis, a pH of 7.25 to 7.35 with a raised carbon dioxide, despite maximal medical therapy. Below pH 7.25 it may still be used, but in a higher dependency setting with intubation considered.
“BiPAP for type 2 failure, CPAP for type 1 with pulmonary oedema” is the pairing to carry.
A ceiling of treatment should be agreed early, before deterioration, since many of these patients have advanced disease and the decision is far harder to make in crisis.
Never withhold oxygen from a hypoxic patient for fear of carbon dioxide retention. Hypoxia kills faster than hypercapnia; the correct response to a rising carbon dioxide is controlled oxygen and ventilation, not less oxygen.