Complications and Emergency Management

Severe Exacerbations and Respiratory Failure

• Severe exacerbations are life-threatening events requiring emergency management and hospitalization.
• Cardinal features include severe dyspnea at rest, use of accessory muscles, mental status changes, hemodynamic instability, and presence of comorbid conditions.
• Respiratory failure is defined as acute hypoxemia (PaO2 < 60 mmHg) and/or hypercapnia (PaCO2 > 50 mmHg) with acidosis (pH < 7.35).
• Immediate management focuses on supporting ventilation, oxygenation, and hemodynamic status while determining the need for aggressive interventions.

Ventilatory Support

• Noninvasive positive pressure ventilation (NIPPV) is first-line for respiratory failure without contraindications like hypotension or altered mental status. Improves gas exchange and reduces intubation risk.
• Invasive mechanical ventilation is indicated if NIPPV fails or is contraindicated. Patients may require intubation, sedation, and admission to the ICU.
• Extracorporeal membrane oxygenation (ECMO) may be considered in refractory hypoxia despite protective lung ventilation strategies.

Associated Complications

• Hemodynamic instability – Perform ECG to evaluate for myocardial ischemia or arrhythmias. Administer intravenous fluids cautiously to avoid volume overload. Vasopressors may be needed to support blood pressure.
• Metabolic disturbances – Corticosteroids can worsen hyperglycemia. Monitor glucose and electrolytes.
• Alterations in mental status – Assess for hypercapnic encephalopathy. Neuroimaging may be needed to exclude alternative causes.
• Stress ulcers – Prophylaxis against gastrointestinal bleeding.

Early recognition of respiratory failure is key. A coordinated emergency response involving providers from multiple specialties is often needed to stabilize patients and prevent further clinical deterioration.