Respiratory
COPD exacerbation — the essentials
An acute exacerbation of COPD (AECOPD) is acute worsening of dyspnea, sputum volume, and sputum purulence — the Anthonisen triad — in a chronic CO2-retainer at risk of type II respiratory failure. The biggest nursing error is over-oxygenation. The priority is to recognize work of breathing and early hypercapnia, titrate oxygen WITHIN the ordered 88-92% target with a controlled device, give bronchodilators/steroids/antibiotics per order, and escalate to NIV when respiratory acidosis appears.
Recognize it (red flags)
- Anthonisen triad: increased dyspnea + increased sputum VOLUME + change to PURULENT (yellow/green) sputum
- Accessory-muscle use, pursed-lip breathing, tripod positioning, speaking in short phrases, prolonged expiratory phase with wheeze
- Early hypercapnia — do NOT mislabel as "improving" or "sedated": drowsiness, confusion, headache, warm flushed peripheries, bounding pulse, asterixis
- Falling SpO2 despite controlled oxygen OR rising drowsiness/confusion = impending CO2 narcosis — stop escalating FiO2, reassess, escalate
- Silent chest, RR >30 with paradoxical breathing, or inability to speak = respiratory muscle fatigue near arrest — rapid response
Key numbers
- Target SpO2 (at-risk retainer)
- 88-92% — do NOT target >92%
- Controlled oxygen device
- Venturi mask, commonly starting 24-28% per order
- NIV (BiPAP) indication
- pH <7.35 with PaCO2 >45 mmHg (acute respiratory acidosis)
- Life-threatening failure
- pH <=7.25, PaCO2 >60 mmHg, altered mental status
- Antibiotics
- only when ALL 3 Anthonisen symptoms are present; typical course 5-7 days
- Serum potassium check
- within 2 h of first SABA (beta-agonist hypokalemia)
- Blood glucose
- q4h on systemic corticosteroid
Priority nursing actions
- Do the focused respiratory assessment — rate, effort, accessory-muscle/tripod/pursed-lip cues, auscultation, sputum, and level of consciousness (the earliest hypercapnia signal)
- Apply controlled oxygen with a Venturi mask and titrate WITHIN the ordered 88-92% band; titrate DOWN if SpO2 climbs above 92% in a known retainer
- Sit the patient upright/high-Fowler, and administer nebulized salbutamol + ipratropium, systemic corticosteroid, and antibiotics (when sputum is purulent) per order
- Obtain/assist with the ABG and recognize and report the trend (rising PaCO2, falling pH) — do not make the formal diagnostic interpretation
- Notify the provider / activate rapid response for any red flag and set up/assist with NIV once ordered, then reassess the response
Common NGN / NCLEX traps
- Pushing SpO2 to "normal" (>=95%) in a CO2-retainer — over-oxygenation can blunt hypoxic drive and worsen hypercapnia
- Reading new drowsiness/confusion as "settling down" or sedation instead of impending CO2 narcosis
- Giving antibiotics when the full Anthonisen triad is NOT present — antibiotics need all three cardinal symptoms
- Independently starting NIV or setting BiPAP parameters — these are ordered; the RN sets up and assists per order
- Ignoring tachycardia/tremor after nebulizers vs a true beta-agonist toxicity — hold the SABA and notify if HR >130 bpm
For practicing nurses
What’s changed (if you trained a while ago)
- The 88-92% controlled-oxygen target is firmly established for patients at risk of hypercapnic failure — higher is not better (BTS 2023, GOLD 2025).
- Antibiotics now require ALL THREE Anthonisen cardinal symptoms simultaneously, not just any worsening (GOLD / BMJ Best Practice 2025); a delay >24 h once indicated is linked to higher mortality.
- Blood eosinophils guide maintenance ICS (>=300 cells/uL for one exacerbation/yr, >=100 for frequent exacerbators) — a maintenance biomarker, NOT a guide for acute titration (GOLD 2025).
- The Canadian Thoracic Society now formalizes vitamin D supplementation (if <25 nmol/L), a 30-day post-discharge follow-up, and pulmonary rehab within 90 days for a mortality benefit (CTS 2025).
On the floor (practical pearls)
- Treat oxygen like a drug: stop escalating FiO2 and reassess if SpO2 trends above 88-92% or the patient becomes drowsy/confused — over-oxygenation can precipitate CO2 narcosis.
- Check serum potassium within 2 h of the first salbutamol treatment — K+ can drop with repeated/high-dose nebulization; hold the SABA and notify for HR >130 bpm or a new arrhythmia.
- Monitor blood glucose q4h on systemic steroids — hyperglycemia is common, especially in diabetics.
- Verify inhaler technique at every encounter — the error rate exceeds 70% without reinforcement, and it is a high-yield readmission-prevention point.
- With ipratropium, protect the eyes from the mist (acute angle-closure risk) and use a mouthpiece or well-fitted mask; caution with glaucoma and urinary retention.
- Chart the SpO2 against the ordered band, the ABG trend, work of breathing, and LOC — escalate for pH <=7.35 with PaCO2 >=45 mmHg persisting after ~1 h, or any sign of fatigue.
Key references
- Global Strategy for Prevention, Diagnosis and Management of COPD (GOLD Report), GOLD, 2025
- BTS Guideline for Oxygen Use in Adults in Healthcare and Emergency Settings, BTS, 2017
- Anthonisen NR et al. — exacerbation criteria, Ann Intern Med
- Lewis's Medical-Surgical Nursing (Harding/Lewis), Elsevier, 2023
- Davis's Drug Guide for Nurses, F.A. Davis, 2024
Sources: Based on GOLD 2025, the BTS 2023 Oxygen Use guideline, the Canadian Thoracic Society 2025, BMJ Best Practice (2025), and Lewis Medical-Surgical Nursing / Davis’s Drug Guide.
