In a COPD exacerbation, the nurse manages the two things that change fastest: how hard the patient is working to breathe, and how their oxygen and carbon dioxide balance is trending. Here is what to watch, what to do, and when to call.

Support oxygenation without overshooting

COPD is the classic case where more oxygen is not better. Titrate to a target of 88 to 92 percent, using the lowest flow that holds that range, often starting around 1 to 2 liters per minute by nasal cannula. High-concentration oxygen in a patient who retains carbon dioxide can worsen hypercapnia, and controlled oxygen therapy has been shown to more than halve mortality compared with routine high-flow oxygen. If saturations will not hold or the patient tires, that is an escalation, not a reason to keep turning the oxygen up.

Position and pace the work of breathing

  • Sit the patient upright or forward in the tripod position so accessory muscles can work.
  • Coach pursed-lip breathing to slow the respiratory rate and keep airways open on exhalation.
  • Cluster care and allow rest. Talking, eating, and walking all cost this patient breath.

Medications you will be giving

  • Short-acting bronchodilators such as albuterol, often with ipratropium, by nebulizer or inhaler.
  • Systemic corticosteroids to reduce airway inflammation.
  • Antibiotics when the exacerbation is driven by infection, signaled by increased sputum volume or purulence.

Watch for tremor and tachycardia after bronchodilators, and check glucose on steroids.

Monitor the trend, not just the number

  • Respiratory rate, effort, and accessory muscle use.
  • Oxygen saturation against the 88 to 92 target.
  • Mental status. A patient who was anxious and is now drowsy may be retaining carbon dioxide.
  • Arterial blood gases as ordered, to see the carbon dioxide and pH, not just the saturation.

When to escalate

Rising respiratory rate with falling saturations, new drowsiness or confusion, or a patient who says they cannot keep this up. A quiet chest or one-word answers mean call now.

Teach before discharge

  • Inhaler technique with teach-back, and spacer use.
  • The action plan: which symptoms mean rescue inhaler, which mean call, which mean go in.
  • Smoking cessation support and vaccination.

For the full clinical picture, see the free COPD nursing care plan, and keep your assessments and oxygen trend organized on a free brain sheet.

Sources: emergency oxygen guidance on controlled therapy targeting 88 to 92 percent in COPD. Follow your facility protocol.