Management of acute exacerbations of chronic obstructive pulmonary disease: the first 24 hours.

Successful outcome is more likely with early treatment and lesser degrees of acidosis. While aiming for maximum treatment for the first 24 hours, some patients improve so rapidly that they can discontinue after a shorter time. Most patients need a full face mask and oxygen, and nebulised bronchodilators can be incorporated. If radiological consolidation, excessive secretions and/or confusion are present, the chance of failure is increased but is not an absolute contraindication. The presence of a pneumothorax necessitates intercostal drainage. A useful summary statement has recently been published. Patients who are obtunded and peri-arrest require immediate intubation and mechanical ventilation. There is some evidence that intensivists are reluctant to accept COPD exacerbators to the intensive care unit because of the perceived low survival rates or concerns about weaning delays after intubation. In fact, the prognosis may be better than in many other patients with multi-organ failure. Patients can often be quickly weaned on to NIV and returned to the ward after an initial period of invasive support and secretion management. Initial assessment and the past history should identify those markedly disabled patients with recurrent admissions who are likely to be entering the terminal stages of their illness in whom intubation is inappropriate. Here, NIV may be the ceiling of treatment, providing useful symptom palliation while waiting for treatment to