Managing Acute Shortness of Breath in a Patient with COPD

Scenario

Your COPD patient on 2 L/min nasal cannula becomes acutely short of breath, with SpO₂ 86%, RR 32, use of accessory muscles, and anxious restlessness.
They say, “I can’t catch my breath,” and appear cyanotic around lips.

Question: What are your immediate actions, and how do you manage this acute respiratory episode safely?

Best Practice Answer

1. Recognize Acute Exacerbation and Act Immediately:
   This presentation suggests acute hypoxemic or hypercapnic exacerbation.
   Prioritize airway, breathing, circulation (ABC) — COPD patients can fatigue quickly and decompensate suddenly.

2. Immediate Nursing Interventions (First 1–2 Minutes):

   • Raise the head of the bed to high Fowler’s to improve ventilation.
   • Encourage pursed-lip breathing to slow exhalation and reduce air trapping.
   • Increase oxygen flow cautiously:
     • Raise from 2 L to 3–4 L/min, aiming for SpO₂ 88–92% (avoid over-oxygenation which may suppress respiratory drive).
   • Assess airway patency and listen for wheezing or diminished breath sounds.
   • Remain with the patient — anxiety worsens hypoxia.

3. Collaborate and Escalate:

   • Notify provider or Rapid Response if SpO₂ < 88% despite oxygen increase.
   • Prepare for nebulized bronchodilator therapy (e.g., albuterol/ipratropium).
   • Anticipate orders for systemic corticosteroids and ABG analysis.
   • Assess for infection — productive cough, fever, or increased sputum may indicate need for antibiotics.
   • Maintain IV access in case of escalation to IV steroids or fluids.

4. Ongoing Monitoring:

   • Reassess vitals, lung sounds, and SpO₂ every 5 minutes during the episode.
   • Watch for signs of CO₂ retention: confusion, drowsiness, or a sudden rise in somnolence.
   • Be prepared for BiPAP initiation or intubation if patient becomes lethargic or unresponsive.

5. Patient Education (After Stabilization):

   • Reinforce breathing techniques (pursed-lip, diaphragmatic).
   • Encourage slow pacing with activity and use of rescue inhaler early at symptom onset.
   • Discuss avoidance of triggers (smoke, cold air, infection).
   • Review importance of medication adherence and vaccination (influenza, pneumococcal).

6. Documentation:

   • Record onset, symptoms, interventions, and response.
   • Include O₂ flow changes, provider notification time, and medications administered.
   • Chart SpO₂ trend and patient tolerance throughout event.

Real-World Application

This scenario evaluates your ability to act decisively under respiratory distress — one of the most common emergencies in med-surg and telemetry units.
Interviewers want to see whether you:

• Recognize early hypoxia signs
• Manage O₂ safely in chronic CO₂ retainers
• Communicate effectively under pressure
• Combine clinical skill with patient reassurance

These responses reflect the hallmark of critical situational nursing judgment.

Tip: In interviews, phrase it clearly —
“For a COPD patient in distress, I’d raise the HOB, use pursed-lip breathing, titrate O₂ carefully to 88–92%, prepare bronchodilators, and notify the provider immediately.”
This shows safe oxygen management, situational awareness, and clinical precision.