Hub CPD handout

COPD, Type 2 Respiratory Failure and NEWS2

JRCALC Chronic Obstructive Pulmonary Disease · RCP NEWS2

Summary of current (as at 19/09/2026) JRCALC and Trust notices. Recheck the live guideline, local PGDs and stock before you treat.

Five key points to remember

Two separate decisions

Oxygen target — JRCALC

Known or suspected COPD: start with 88–92% (or the alert-card range) unless they are critically ill.

This is a treatment decision. It is not NEWS2 Scale 2.

NEWS2 scale — RCP

Use Scale 1 unless type 2 (hypercapnic) failure is already documented: alert card stating type 2 / raised CO₂, specialist plan, previous ABG, or Hub special message.

Routinely, look for that record before Scale 2. JRCALC is less absolute than a hard ban, and there can be exceptions — if you use Scale 2 without it, say why at handover.

When Scale 2 may be applied

Apply their record

Type 2 already confirmed on blood gas
A hospital doctor, ANP or specialist has already recorded it
You can see that documentation

The usual role on scene is to apply that record. Scene findings alone are not a reason to start Scale 2.

Do not switch scale because

They “have COPD”
They are on home oxygen
They “look like a retainer”
You are targeting 88–92%
The ePR offered Scale 2 when you typed COPD

Same sats, two scores

	68, COPD, no alert card, 90% on air	Same age, alert card: previous type 2, 90% on 28% Venturi
Correct scale	Scale 1 — 90% scores 3. Hypoxia is visible.	Scale 2 — SpO₂ 0 + oxygen 2. Stops staff chasing sats with high-flow.
Wrong habit	Scale 2 scores 90% as 0 and can hide hypoxia.	Scale 1 keeps alarming at 90% and oxygen creeps up.

A usual SpO₂ of 90% scoring 3 is doing its job. Do not switch scale to make the NEWS look nicer. Handover: “NEWS 3, all from sats, usual 90% on air, Scale 1, targeting 88–92%.”

CN-436 sats pre-alert

The sats line is ≤91% on oxygen (or ≤83% if chronic hypercapnic failure is already documented). 90% on air scores 3 on Scale 1 — it does not by itself meet that sats pre-alert. Other red physiology still alerts. So does significant clinical concern.

Oxygen and nebulisers

Not critically ill

Start the white 28% Venturi at 4 L/min
Step up to red 40% if that is not reaching target
RR >30 on a Venturi: increase flow 50% above the mask minimum — same mask

Oxygen-driven neb

Salbutamol 5 mg. Repeat every 5 min if needed. No written maximum number of salbutamol doses
Oxygen may drive each neb for 6 minutes, then stop and aim 88–92%
Ipratropium 500 micrograms once if severe
Hydrocortisone 100 mg slow IV or IM

Critically ill

Do not withhold high-flow / reservoir
TIME-CRITICAL and ATMIST
Titrate 88–92% once they are no longer critical
The 6-minute rule is neb drive only — not a timer on oxygen given for hypoxia

JRCALC / AACES COPD guidance does not write a maximum of two oxygen-powered nebs. It limits how long oxygen drives each nebuliser. Between runs: off the neb mask, titrate to 88–92%. Applies if COPD is a possibility — not only proven type 2 failure.

Check yourself

Question	Answer
Default NEWS2 SpO₂ scale for a known COPD patient?	Scale 1, unless type 2 failure is already documented.
Every COPD patient on Scale 2?	False. JRCALC / AACES COPD guidance says some are at increased risk of type 2 failure — not all.
Target 88–92% and still use Scale 1?	Yes. Oxygen target and scoring scale are separate.
COPD, shocked, SpO₂ 80%, BP 86/50 — high-flow or low-flow?	High-flow now. Hypoxia is the greater short-term risk. Titrate once they improve.
How long may oxygen drive a neb in COPD?	6 minutes per run, then stop. Not “until the chamber is empty”.
Chest pain and fever in “COPD”?	Uncommon in a simple exacerbation. Reconsider pneumonia, ACS, PE, pneumothorax, heart failure.

Handover that receiving staff can use

“NEWS 3 on Scale 1, targeting 88–92%, 90% on 28% Venturi, no documented type 2.”

Give the total and the components. Say the scale. Say usual sats if known. Say the device and target.

JRCALC / AACES COPD guidance v20.40 (6 September 2023); JRCALC Oxygen, Salbutamol D0300, Ipratropium D0200, Hydrocortisone D0180. RCP, National Early Warning Score (NEWS) 2, 2017 and additional implementation guidance, March 2020. Williams B. Clin Med 2019;19:94–95. WMAS CN-436 Pre-alerting of Patients V8 (20 July 2026). Self-guided slides: add ?view=self to the deck URL. This is not a substitute for the live JRCALC entry or Trust policy.