COPD Exacerbation: Early Mobilisation on the Ward
A 72-year-old woman with severe COPD (FEV1 38% predicted) is admitted with an exacerbation, day 2 of treatment. She is on 2 litres nasal oxygen with target saturations 88-92%, has purulent sputum, and is afebrile. Resting respiratory rate is 24, heart rate 96, and she desaturates to 84% on standing. She uses accessory muscles and has a barrel chest with reduced basal air entry. She lives alone and her main concern is getting home rather than becoming fitter. She is anxious about moving because 'last time I couldn't breathe'.
1. Is early mobilisation appropriate on day 2, and how would you decide and monitor it?
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Yes, provided it is graded and monitored, because prolonged bed rest worsens deconditioning, sputum clearance, and function. But she is not ready for an endurance walk. I would use a symptom-led approach with objective stop criteria: oxygen saturation below 88% (or her individualised target), respiratory rate above 30, heart rate above a safe ceiling based on age-predicted maximum, new arrhythmia, chest pain, or distress. Her desaturation to 84% on standing means she needs oxygen titrated during activity, not just at rest, and a seated rest before proceeding.
Start with bed exercises, sitting balance, active cycle of breathing and supported huffing for sputum clearance, then standing and marching on the spot, then walking to the door and back with a chair positioned. Keep sessions short (2-3 minutes of activity, then rest) and repeat several times a day rather than one long session. I would coordinate with nursing and respiratory physiotherapy, check she has had bronchodilators, and document the plan and stop criteria in the notes so other staff continue it safely.
2. Her goal is discharge home. What would you prioritise, and what would you recommend at discharge?
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Her stated goal is function at home, so I would prioritise the tasks she actually needs: getting from bed to chair, walking to the toilet, managing stairs if she has them, and washing and dressing with her breathlessness. I would assess her with her own equipment and oxygen delivery, and check her inhaler technique and whether she has a rescue pack and an action plan.
Discharge recommendations: a short course of supervised walking with pacing and pursed-lip breathing, an energy-conservation plan for household tasks, referral to pulmonary rehabilitation (which reduces readmission and improves quality of life) starting after recovery, and a home oxygen assessment if she meets criteria. I would involve social care given she lives alone, and ensure she can contact services if breathlessness worsens. I would give written safety-net advice and a follow-up appointment, and record that she declined 'fitness' goals but accepted function-based ones, so the plan matches her priorities.