# A 68-year-old client with COPD is admitted with shortness of breath and SpO2 86% on room air. The provider orders supplemental oxygen. Which is the most appropriate initial oxygen delivery for this client?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=362940&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 68-year-old client with COPD is admitted with shortness of breath and SpO2 86% on room air. The provider orders supplemental oxygen. Which is the most appropriate initial oxygen delivery for this client?

## Option

1. Simple face mask at 8 L/min
2. Non-rebreather mask at 15 L/min
3. Bag-valve-mask ventilation at 100% FiO2
4. Nasal cannula at 2 L/min **✔ Correct answer**

**Correct answer: 4**

## Explanation

COPD clients with chronic CO2 retention rely on hypoxic drive for respiratory stimulation. High-flow oxygen can suppress this drive and cause CO2 narcosis and respiratory failure. GOLD guidelines target SpO2 88 to 92 percent in COPD using low-flow nasal cannula first (1 to 2 L/min) and titrating up. Higher delivery devices are reserved for refractory hypoxemia under provider guidance.

## In-depth explanation

Clinical Judgment
Some COPD clients are CO2 retainers who depend on the hypoxic drive. Aggressive oxygen removes this drive and causes hypoventilation. Target SpO2 88-92%, not 100%. Start low-flow nasal cannula 1-2 L/min and titrate.

Memory Tip
COPD O2: start low, titrate to 88-92% — not 95+

KR vs US
GOLD 2025 (used in both US and Korea) recommends 88-92% target. Korean tertiary EDs follow the same low-flow first protocol; venturi mask may be added for precision when nasal cannula is insufficient.

## Clinical scenario

Clinical Practice Guide
GOLD 2025 standards: in COPD with acute exacerbation, titrate oxygen to SpO2 88-92% using low-flow nasal cannula 1-2 L/min initially. Add Venturi mask (24-28%) if nasal cannula insufficient. Obtain ABG within 30-60 min to verify ventilation and avoid CO2 narcosis.

Caution
Withholding oxygen for fear of CO2 retention is also dangerous. Treat hypoxemia first with the lowest effective flow. Monitor mental status — drowsiness or confusion may signal rising CO2.

## Key concepts

- **Hypoxic drive** — Respiratory drive triggered by low PaO2 rather than rising PaCO2. Develops in some chronic CO2 retainers (advanced COPD). Excess oxygen abolishes this drive and causes hypoventilation and CO2 narcosis.
- **SpO2 target** — Standard target in most adults: 94% or higher. COPD with chronic CO2 retention: 88-92% target to preserve hypoxic drive while correcting hypoxemia. Reassess every shift.
- **Venturi mask** — High-flow precision oxygen device delivering exact FiO2 (24, 28, 31, 35, 40%) regardless of breathing pattern. Preferred for COPD when nasal cannula is insufficient because it allows tight FiO2 control.

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