A nurse is caring for a client with COPD who is experiencing an acute exacerbation. The client's oxygen saturation is 88% on room air, respiratory rate is 28/min, and the client is using accessory muscles. The client appears anxious and states "I can't catch my breath." ABG results show: pH 7.25, PaCO2 70 mmHg, PaO2 55 mmHg, HCO3- 32 mEq/L. Which nursing intervention should be the priority?

In COPD exacerbation with hypoxemia (SpO2 88%), low-flow oxygen (1-2 L/min) is priority to correct hypoxia while avoiding suppression of hypoxic drive. Other interventions are important but secondary to immediate oxygenation.

Clinical Context and ABG Interpretation
The client is experiencing an acute exacerbation of COPD. The ABG reveals a pH of 7.25, a PaCO2 of 70 mmHg, a PaO2 of 55 mmHg, and an HCO3- of 32 mEq/L. This pattern indicates a primary respiratory acidosis (elevated PaCO2 lowering the pH) with partial metabolic compensation (elevated HCO3-). The core pathophysiological problem is hypoxemia and hypercapnia, which are driving the client's distress, anxiety, and increased work of breathing.

Priority Intervention Rationale
The priority is to apply low-flow oxygen therapy at 1-2 L/min via nasal cannula. In COPD patients with chronic CO2 retention, the primary respiratory drive can shift from a response to elevated CO2 to a reliance on the hypoxic drive. Correcting the life-threatening hypoxemia is the immediate goal, but it must be done cautiously. Administering high concentrations of oxygen can suppress this hypoxic drive, leading to further hypoventilation, worsening hypercapnia, and potential respiratory arrest. The initial assessment of respiratory distress emphasizes securing oxygenation while carefully monitoring for its effect on ventilation ^[1].

Why Not the Other Options
- Administer bronchodilator medication: While bronchodilators are a cornerstone of COPD exacerbation management to relieve bronchospasm, their effect is not immediate. The priority is to first address the critical hypoxemia that poses an imminent threat to life.
- Position the client in high Fowler's position: This is an important and supportive intervention to maximize chest expansion and lung volumes. However, it does not directly address the severe hypoxemia (PaO2 55 mmHg) as the primary physiological insult. It should be performed concurrently, but oxygenation takes precedence.
- Encourage pursed-lip breathing techniques: This technique helps create back pressure to keep airways open during exhalation, reducing air trapping and improving ventilation. It is a valuable strategy for managing dyspnea in stable COPD or after the acute crisis is resolving, but it is not the first-line intervention for a patient in acute respiratory failure with profound hypoxemia. The immediate need is to improve the oxygen content in the arterial blood.