# A 68-year-old with COPD has worsening dyspnea and purulent sputum. Findings are RR 28/min, SpO2 84% on room air, pH 7.30, PaCO2 62 mmHg, PaO2 56 mmHg, and HCO3 30 mEq/L. Which initial actions are appropriate? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=368314&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A 68-year-old with COPD has worsening dyspnea and purulent sputum. Findings are RR 28/min, SpO2 84% on room air, pH 7.30, PaCO2 62 mmHg, PaO2 56 mmHg, and HCO3 30 mEq/L. Which initial actions are appropriate? Select all that apply. 1 Start controlled supplemental oxygen and titrate to an SpO2 target of 88% to 92%, then reassess blood gases and clinical response 2 Postpone bronchodilator and corticosteroid treatment until another arterial blood gas is obtained in 2 hours to establish a trend 3 Place the client supine and discourage coughing so the client conserves energy and reduces oxygen consumption during respiratory distress 4 Position the client upright, permit a tripod position, coach pursed-lip breathing, and maintain a calm presence while assessing work of breathing 5 Apply uncontrolled 100% oxygen and target an SpO2 of 100% without reassessing carbon dioxide retention or worsening acidosis 6 Administer prescribed short-acting inhaled bronchodilators, such as albuterol with ipratropium, to treat acute airflow obstruction ## Explanation This client has an acute COPD exacerbation with acute-on-chronic hypercapnic respiratory acidosis. Give controlled oxygen titrated to 88% to 92% and reassess gas exchange; the concern with excessive oxygen is worsening hypercapnia through mechanisms such as ventilation-perfusion mismatch and the Haldane effect, not simple loss of a 'hypoxic drive' (Choice 1). Upright or tripod positioning and pursed-lip breathing can reduce work of breathing (Choice 4). Short-acting bronchodilators are initial treatment (Choice 6), and prescribed systemic corticosteroids and antibiotics should not be delayed when indicated (Choice 2). Supine positioning and suppressing productive cough impair ventilation and secretion clearance (Choice 3). Uncontrolled oxygen targeting 100% can worsen hypercapnia; because pH is 7.30, the team should also assess promptly for noninvasive ventilation (Choice 5). ## In-depth explanation COPD Acute Exacerbation — Initial Care 1. Controlled low-flow O2 nasal cannula 1-2 L/min, titrate to SpO2 88-92% (avoid 100% in CO2 retainer) 2. Nebulized SABA + SAMA: albuterol + ipratropium (DuoNeb) 3. Systemic corticosteroid: prednisone 40 mg PO × 5 days or methylprednisolone IV 4. Antibiotics if increased sputum purulence + volume + dyspnea (Anthonisen criteria) 5. Position: high-Fowler/tripod; pursed-lip breathing 6. Reassess: SpO2 trend, RR, mental status, ABG if not improving — escalate to BiPAP if hypercapnia/acidosis worsens ABG in COPD This client: pH 7.30, PaCO2 62, HCO3 30 → acute on chronic respiratory acidosis with partial metabolic compensation. Chronic baseline likely had pH 7.36-7.40 and PaCO2 50-55; now acutely worse. Why Avoid 100% Oxygen Chronic CO2 retainers depend partly on the hypoxic respiratory drive. Excess oxygen → suppresses drive → CO2 rises further → respiratory acidosis worsens → CO2 narcosis and respiratory arrest. Target SpO2 88-92%. Pursed-Lip Breathing Inhale slowly through the nose; exhale slowly through pursed lips for ~4-6 seconds. Generates internal PEEP, prevents premature airway collapse, and reduces dynamic hyperinflation. Memory Tip "88-92 + DuoNeb + Steroid + Sit Up" ## Clinical scenario Scenario 68 yo with long-standing COPD, 3 days of dyspnea + thick yellow sputum + wheezing. RR 28, SpO2 84% RA, ABG pH 7.30/PaCO2 62/PaO2 56/HCO3 30 = acute on chronic respiratory acidosis. Initial Care Bundle 1. Controlled O2 NC 1-2 L/min → SpO2 88-92% 2. Nebulized albuterol + ipratropium (SABA + SAMA) 3. Systemic corticosteroid (prednisone PO or methylprednisolone IV) 4. Consider antibiotics (purulent sputum + volume + dyspnea) 5. High-Fowler/tripod + pursed-lip breathing + calm presence 6. Reassess; escalate to BiPAP if worsening hypercapnia/acidosis Avoid - 100% non-rebreather targeting 100% - Supine positioning - Suppressing cough - Waiting on repeat ABG before treating ## Key concepts - **COPD Acute Exacerbation** — Acute worsening of COPD symptoms (dyspnea, cough, sputum volume/purulence) beyond day-to-day variation that requires escalation of therapy. Often triggered by viral or bacterial respiratory infection, environmental pollution, or non-adherence. First-line: controlled low-flow oxygen titrated to SpO2 88-92%, nebulized short-acting beta agonist + anticholinergic (albuterol + ipratropium), systemic corticosteroid (prednisone 40 mg PO daily for 5 days), and antibiotics when purulence is increased. Escalate to noninvasive ventilation (BiPAP) if hypercapnia and acidosis worsen. - **Controlled Oxygen Therapy in CO2 Retainers** — Chronic CO2 retainers (often advanced COPD) may depend partly on hypoxic respiratory drive. Excessive supplemental oxygen can suppress this drive, worsen ventilation-perfusion mismatch, and increase CO2 — precipitating CO2 narcosis and respiratory arrest. Standard: titrate oxygen to SpO2 target 88-92% rather than 95-100%, using the lowest effective FiO2 (often nasal cannula 1-2 L/min). Reassess frequently; if SpO2 cannot be maintained at target with low-flow O2, escalate to BiPAP rather than high-flow oxygen alone. - **ABG Interpretation in COPD** — Chronic CO2 retention typical baseline: pH 7.36-7.40, PaCO2 50-55, HCO3 28-32 (chronic respiratory acidosis with metabolic compensation). Acute exacerbation: pH falls (often <7.35 or <7.30 if severe), PaCO2 rises further, HCO3 already elevated from compensation. The pattern in this client (pH 7.30, PaCO2 62, HCO3 30) is acute on chronic respiratory acidosis with partial metabolic compensation. NIPPV (BiPAP) is indicated when pH <7.35 with hypercapnia despite optimal medical therapy. ## Related questions - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en) - [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en) - [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en) - [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en) - [A nurse is caring for an adult client admitted with diabetic ketoacidosis. 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