COPD Exacerbation: Nursing Care, Controlled Oxygen and Non-Invasive Ventilation

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide, according to WHO, and most deaths occur in low- and middle-income countries. Smoking is the main cause in high-income countries, but in much of Africa and Asia, household air pollution from cooking with wood, charcoal and kerosene is a major cause, particularly among women. Flare-ups (exacerbations) are a common reason for hospital admission, and nursing care makes a large difference to outcomes.

Recognising an exacerbation

• Worsening breathlessness beyond day-to-day variation.
• Increased cough and sputum volume; change in sputum colour (purulent).
• Wheeze, chest tightness, fatigue.
• Common triggers: viral and bacterial infections, air pollution, stopping medicines.

Danger signs

• Respiratory rate above 30; use of accessory muscles; unable to speak in sentences.
• New confusion, drowsiness or a flapping tremor: signs of rising CO₂.
• Cyanosis, falling SpO₂ despite oxygen.
• Signs of right heart failure: new ankle swelling.

Controlled oxygen: the 88–92% target

Many people with COPD rely partly on low oxygen levels to drive their breathing, and too much oxygen can cause CO₂ to rise dangerously (hypercapnic respiratory failure). The British Thoracic Society recommends a target of 88–92% for patients at risk, until blood gases are known. Use a Venturi mask (24% or 28%) or low-flow nasal cannula, and check blood gases. Many patients carry an oxygen alert card stating their target. See our oxygen therapy guide.

Never withhold oxygen from a hypoxic patient for fear of CO₂ retention: give controlled oxygen and monitor closely.

Treatment nurses deliver

• Bronchodilators: salbutamol and ipratropium by nebuliser or inhaler with spacer, as prescribed. In CO₂ retainers, nebulisers are usually driven by air with oxygen given separately by nasal cannula, to avoid high oxygen levels.
• Oral steroids: commonly prednisolone 30 mg daily for 5 days (NICE), as prescribed.
• Antibiotics if signs of bacterial infection, such as purulent sputum.
• VTE prophylaxis and fluids as prescribed.

Non-invasive ventilation (NIV)

For patients with acute hypercapnic respiratory failure (pH below 7.35 with raised CO₂ despite optimal treatment), NIV (often called BiPAP) through a tight-fitting mask can avoid intubation and reduce deaths. Nursing care is intensive:

• Explain and reassure: the mask feels claustrophobic at first.
• Fit the mask correctly: not too tight; check for leaks.
• Protect the skin on the bridge of the nose with dressings; check frequently.
• Monitor SpO₂, RR, heart rate, conscious level and synchrony with the ventilator; repeat blood gases at 1–2 hours as directed.
• Watch for vomiting and aspiration, and for gastric distension.
• Know the escalation plan: is the patient for intubation if NIV fails?
• Mouth care and fluids during breaks.

Comfort and positioning

• Sit upright or lean forward with arms supported on a table.
• Teach pursed-lip breathing (breathe in through the nose, out slowly through pursed lips) to reduce breathlessness.
• A handheld fan directed at the face can relieve breathlessness.
• Small, frequent meals: breathless patients often struggle to eat and lose weight.
• Help with sputum clearance; involve physiotherapy.
• Anxiety is common: stay calm and reassuring.

Before discharge

• Check inhaler technique: errors are very common. Watch the patient use their inhaler and correct them.
• Stop smoking: the single most effective intervention. Offer support and referral.
• Reduce exposure to smoke from cooking fires: better ventilation, cleaner fuels where possible.
• Vaccinations: influenza and pneumococcal where available.
• Pulmonary rehabilitation referral: exercise and education improve quality of life and reduce readmissions.
• A written self-management plan: recognising early flare-ups and what to do, including any rescue pack.
• Follow-up within a few weeks.

Related: ABG interpretation · NEWS2 and SpO₂ Scale 2 · Acute asthma

Based on NICE NG115 (COPD in over 16s), the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report and BTS oxygen and NIV guidance. Educational content: follow your prescription and local policy.