Acute Asthma & COPD Exacerbation: Step-by-Step Escalation
Walking into a bay to find a patient upright, gasping for air, clutching the bed rails, and using neck muscles to breathe triggers instant panic in any student nurse. Acute respiratory distress from severe asthma or a COPD exacerbation requires rapid assessment, correct oxygen targeting, immediate drug therapy, and structured escalation. Here is your evidence-based roadmap.
“Hypoxia kills quickly; hypercapnia kills slowly. Never withhold high-flow oxygen in an acutely hypoxic patient while waiting for medical review, regardless of whether they have COPD.”
— British Thoracic Society (BTS) Oxygen Guidelines
📎 Source: BTS Oxygen Therapy Guideline
1. Oxygen Targets & Respiratory Failure Types
Correct oxygen delivery depends on identifying the type of respiratory failure:
Causes: Severe asthma, pneumonia, pulmonary embolism, pulmonary oedema
🎯 Target: 94–98% — high-flow 15L/min via non-rebreathe mask during crisis
Causes: Severe COPD, obesity hypoventilation, neuromuscular disease
🎯 Target: 88–92% — controlled oxygen via Venturi or low-flow cannulae
📎 Sources: NICE NG245: Asthma | NICE NG192: COPD | BTS Oxygen Guidelines
⚠️ Local guidelines may vary. Always check your trust’s oxygen policy and follow any target card carried by the patient.
2. First 5 Minutes — Immediate Actions
Sit the patient upright, deliver oxygen appropriately, prepare nebulisers, and escalate:
- Position fully upright — maximises chest expansion; support arms with pillows
- Apply appropriate oxygen — 15L/min non-rebreathe if critically low; 24–28% Venturi if known COPD target 88–92%
- Salbutamol 5mg + Ipratropium 500mcg nebuliser — back-to-back if severe
- Asthma: Drive with oxygen at 6–8 L/min
- COPD: Drive with medical air at 6 L/min + nasal oxygen if SpO₂ < 88%
- Monitor NEWS2 — respiratory rate, oxygen saturations, heart rate, consciousness, temperature, BP
📎 Sources: NICE NG245 (Asthma) | NICE NG192 (COPD)
⚠️ Nebuliser delivery methods may differ locally. Confirm with your ward protocol or supervising nurse.
3. Red Flags — Call 2222 Immediately
Any one of these features indicates life-threatening compromise:
- Silent chest — wheeze absent due to severe airflow limitation
- Cannot speak in full sentences — only single words or none
- Drowsiness, confusion, or exhaustion — rising CO₂ = respiratory fatigue
- Use of accessory muscles / paradoxical abdominal movement
- Bradycardia or falling blood pressure after persistent tachycardia
- SpO₂ < 92% despite maximum oxygen therapy
🚨 Any of these → dial 2222 and state “Medical Emergency” immediately.
📎 Sources: NICE NG245 — Life-Threatening Criteria | NHS England NEWS2
4. Escalation — SBAR Communication Tool
Use this structure when contacting the medical team or Critical Care Outreach:
- S — Situation: Who you are, which patient, what’s happening now
- B — Background: Admission reason, known diagnosis, oxygen target
- A — Assessment: Current vitals, observations, interventions already done
- R — Request: What you need and how urgently
📎 Source: RCN — SBAR Communication Framework
5. Treatments to Prepare at the Bedside
- Arterial Blood Gas (ABG) kit — heparinised syringe, ice pack, sharps bin
- Steroids — oral prednisolone 40–50mg or IV hydrocortisone 100–200mg
- IV Magnesium — 1.2–2g over 20 mins for severe asthma unresponsive to nebs
- NIV / BiPAP setup — if pH < 7.35 on ABG despite optimal medical therapy
📎 Sources: NICE NG245 | NICE NG192
⚠️ Drug doses and protocols vary between trusts. Always check the current British National Formulary (BNF) and local prescribing guidance.
Sepsis Red Flags & Sepsis Six
NEWS2 triggers, one-hour bundle, urgent escalation.
Published by TheStudentNurse.co.uk — Honest, evidence-based support for every student nurse.
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