# A nurse is caring for a 65-year-old client with COPD exacerbation and a history of asthma who has been receiving continuous nebulizer treatments for the past 2 hours and is not responding adequately to initial bronchodilator therapy. The client's peak expiratory flow rate (PEFR) remains at 35% of personal best, oxygen saturation is 90% on 4L nasal cannula, and the client appears increasingly anxious and fatigued. What is the nurse's priority intervention?

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## 문제

A nurse is caring for a 65-year-old client with COPD exacerbation and a history of asthma who has been receiving continuous nebulizer treatments for the past 2 hours and is not responding adequately to initial bronchodilator therapy. The client's peak expiratory flow rate (PEFR) remains at 35% of personal best, oxygen saturation is 90% on 4L nasal cannula, and the client appears increasingly anxious and fatigued. What is the nurse's priority intervention?

The nurse must determine the most appropriate immediate intervention for a client with severe asthma exacerbation who is not responding adequately to initial bronchodilator therapy.

## 보기

1. Prepare for possible intubation and mechanical ventilation **✔ 정답**
2. Increase the oxygen flow rate to 6L via nasal cannula
3. Administer an additional albuterol nebulizer treatment
4. Administer intravenous corticosteroids as prescribed

**정답: 1**

## 해설

With PEFR 35%, SpO2 90% on oxygen, and fatigue/anxiety despite bronchodilators, the client shows signs of impending respiratory failure, making preparation for intubation the priority. Other options are insufficient (increasing oxygen or albuterol) or not immediately life-saving (corticosteroids).

## 심화 해설

Clinical Context & Pathophysiology

This client is experiencing a life-threatening asthma-COPD overlap exacerbation that has progressed despite 2 hours of continuous nebulized bronchodilators. The combination of a PEFR at only 35% of personal best, hypoxemia (SpO₂ 90% on 4L oxygen), and worsening anxiety with fatigue signals impending acute respiratory failure (ARF). In severe asthma and COPD exacerbations, persistent bronchial smooth muscle contraction, airway inflammation, and mucus hypersecretion increase airway resistance and work of breathing [1][2]. When the patient becomes fatigued and anxious, it indicates that compensatory mechanisms are failing and the ability to maintain spontaneous ventilation is deteriorating.

Why Option 1 Is the Priority

Preparing for possible intubation and invasive mechanical ventilation (MV) is the correct priority intervention. In severe exacerbations that are nonresponsive to initial maximal medical therapy, patients are at high risk for developing hypercapnic respiratory failure and respiratory arrest [1][2]. The clinical presentation—persistent severe airflow obstruction (PEFR 35%), inadequate oxygenation, and signs of exhaustion—meets the criteria for impending ventilatory failure. Delaying preparation for airway management in this scenario risks a crash intubation under emergency conditions, which carries higher morbidity. Evidence emphasizes that patients with severe asthma exacerbations who fail to respond to bronchodilators and show progressive fatigue may eventually require invasive MV, and proactive preparation is a critical nursing safety intervention [2].

Why the Other Options Are Incorrect

- Option 2: Increasing oxygen to 6L via nasal cannula addresses hypoxemia but does not correct the underlying problem of severe airflow obstruction and ventilatory failure. While oxygen titration is important, the immediate threat is loss of airway protection and ventilatory drive, not solely hypoxemia. Furthermore, high-flow nasal cannula may not adequately support ventilation in a fatiguing patient with severe obstruction [2].

- Option 3: Administering another albuterol treatment is not the priority because the patient has already received 2 hours of continuous nebulization without adequate response. Additional bronchodilator therapy at this point delays definitive airway management and is unlikely to reverse the severe bronchospasm and fatigue rapidly enough to prevent decompensation [1].

- Option 4: Intravenous corticosteroids are a cornerstone of managing severe exacerbations by reducing airway inflammation, and they should be administered promptly [1]. However, their onset of action takes hours, and they will not immediately reverse the impending ventilatory failure. In the prioritization framework, securing the airway takes precedence over therapies with delayed onset when the patient is actively deteriorating.

Nursing Clinical Reasoning

The nurse must recognize the progression from severe exacerbation to impending respiratory arrest. The triad of persistent severe airflow obstruction, hypoxemia, and exhaustion despite maximal bronchodilator therapy indicates that noninvasive supports may no longer be sufficient, and the patient is approaching the need for invasive MV [2]. The priority nursing action is to prepare the environment, equipment, and team for emergency intubation while continuing to support oxygenation and monitoring the patient closely. This anticipatory approach aligns with the framework for managing life-threatening obstructive lung disease exacerbations in the ICU, where timely escalation to invasive ventilation prevents adverse outcomes [1][2].References (research sources)

- [1]Management of Asthma and COPD Exacerbations in Adults in the ICU.Research articleMein SA, Ferrera MC. (2025) · DOI: 10.1016/j.chstcc.2024.100107

- [2]An Updated Review on the Use of Noninvasive Respiratory Supports in the Management of Severe Asthma Exacerbations.Research articleCuttone G, La Via L, Pappalardo F, Sorbello M, Paternò DS, Piattoli M, Gregoretti C, Misseri G. (2025) · DOI: 10.3390/medicina61020328

## 임상 시나리오

Impending Respiratory Failure in Asthma-COPD OverlapRecognizing the Failure of Maximal Medical Therapy
A PEFR persistently at 35% of personal best after 2 hours of continuous bronchodilators signals a life-threatening exacerbation. The combination of worsening hypoxemia, anxiety, and fatigue indicates failing compensatory mechanisms and impending ventilatory failure.

The priority is to prepare for definitive airway management. Delaying to administer more bronchodilators or systemic corticosteroids, which take hours to work, risks a crash intubation under emergency conditions with higher morbidity.

CautionDo not mistake an increase in oxygen saturation from a higher flow rate for clinical improvement. It does not correct the underlying hypercapnia or increased work of breathing and may delay necessary ventilation.

## 핵심 개념

- **Auto-PEEP** — Intrinsic positive end-expiratory pressure caused by incomplete exhalation due to airway obstruction, increasing the work of breathing and leading to muscle fatigue.
- **Peak Expiratory Flow Rate (PEFR)** — A measure of airflow obstruction; a value below 40% of personal best indicates a severe exacerbation.
- **Respiratory Muscle Fatigue** — The inability of respiratory muscles to sustain adequate ventilation, signaled clinically by a shift from anxiety/tachypnea to fatigue and somnolence.

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