A 67 year old gentleman is brought in by ambulance to the Emergency Department Resus with a productive cough of green sputum and increasing SOB over a few days.

On Examination

  • PMHx:  Moderate-severe COPD, hypertension, arthritis

  • SHx: Ex-smoker having given up earlier this year. 50 pack year history. Lives alone. BD carers. Known to REDS team.  Struggling at home and considering warden controlled residence.

  • DH - NKDA, on optimal medical treatment. Not on home oxygen.

  • Has had several admissions to the Emergency Department and CDU with exacerbations of COPD requiring several courses of steroids and antibiotics.  NIV required on 2 previous occasions. 

  • On examination he is distressed but orientated in time and place. GCS 15

  • Temperature 37.8, HR 110 regular, RR 28, sats 90% on 28% O2, BP 110/56

  • ABG on 28% Oxygen

  • pH – 7.28

  • pCO2 – 9.1

  • pO2 – 8.0

  • HCO3 – 29.2

  • BE – 2.0

  • Lactate – 1.9

  • Urea – 10.2


Answer one question before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. The first part of teaching will be spent discussing this case:

  1. What are your differential diagnoses for this patient and why?

  2. What is your ABC approach to this patient including initial investigations and management in accordance with the clinical stem and the ABG result?

    Following optimal medical management the patients blood gases fail to improve.

  3. What are the clinical inclusion and exclusion criteria for NIV?

  4. What is NIV?

  5. What is his CURB 65 score and what is the clinical implication of this?

  6. If the patient fails to improve what equipment checks would you undertake and how would you address a persistently raised PaCO2?

  7. The patient fails to respond to NIV one hour later. What considerations and discussions should have happened prior to commencing NIV and what are your management options now?