COPD exacerbation, day 2, and a request to walk to the toilet
Mr P is 74 and was admitted 48 hours ago with an acute exacerbation of COPD. He is on 2 L/min nasal cannula with SpO2 90%, respiratory rate 24, heart rate 104, BP 138/82 and temperature 37.8°C. He is using accessory muscles and speaking in three- to four-word sentences, with an audible expiratory wheeze. Admission arterial blood gas: pH 7.36, PaCO2 52 mmHg, PaO2 58 mmHg. He has been in bed for two days, has had three falls in the past year, and asks to walk to the toilet. The nurse asks you to "get him up and walking today". His bronchodilators were charted 20 minutes ago but he has not yet taken them.
1. Do you walk him to the toilet now? Justify your decision and describe what you would do in the first 30 minutes.
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Decision: not to the toilet now. He is not at rest. Respiratory rate 24 with accessory muscle use and short speech indicate a high work of breathing; he is tachycardic and has not yet received his bronchodilators. A 15–20 m walk to the toilet and back, plus the effort of toileting, is a moderate-intensity task and the wrong starting point.
First 30 minutes
- Confirm with nursing that bronchodilators are given now; plan to reassess in 20–30 minutes.
- Optimise position while waiting: high side-lying or forward-lean sitting with arms supported, feet flat, which reduces dyspnoea and improves diaphragm excursion.
- Do active-assisted range of movement, bed mobility practice and supported sitting balance - meaningful work for deconditioning that does not require high ventilatory demand.
- For toileting, use a commode by the bed with supervision rather than the walk.
- Reassess after bronchodilation: work of breathing, speech length, RR, HR, SpO2.
- Oxygen caution: he is a CO2 retainer (PaCO2 52). Target SpO2 88–92%; do not increase oxygen to chase a "normal" number, and do not titrate above ~92%.
- If he improves, start with 1–2 sit-to-stands to a chair, then a short walk with a rollator and one or two staff, oxygen as prescribed, portable saturation monitoring.
Stop criteria (state them to the nurse): SpO2 <88% or a fall of >4% from baseline, RR >30, HR >120 or a new arrhythmia, new chest pain, confusion, or inability to speak.
2. During sit-to-stand his SpO2 falls to 84%, respiratory rate rises to 32, and he becomes distressed. What do you do, and what do you conclude for the rest of the week?
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Immediate action
- Stop and sit him down, forward lean, arms supported, feet flat.
- Coach breathing control and pursed-lip breathing; calm, slow your own speech and pace.
- Check that the nasal cannula is in place and not dislodged, and titrate oxygen within the prescribed target (88–92%).
- Recheck SpO2, RR, HR and conscious state every 1–2 minutes until recovered.
- If he does not recover promptly, or develops chest pain, drowsiness, increasing confusion or new cyanosis, escalate to the medical team and consider repeat blood gases.
- Document the event, the trigger, the recovery time and who was informed.
Interpretation The desaturation is likely from dynamic hyperinflation: the effort of standing increased his respiratory rate, shortened expiration and caused air trapping. That is a dose and technique problem, not a reason for permanent bed rest.
Plan for the week
- Reduce bout duration and increase frequency: 3–5 short sessions daily rather than one long one.
- Precede activity with bronchodilator; allow 20–30 minutes.
- Teach pacing and pursed-lip breathing before and during the movement, and "blow before you go".
- Use interval work with seated rest, and monitor continuously.
- Escalate concerns about the trajectory - a desaturation to 84% is information the medical team needs, not something to hide.
3. The nurse says: "Why bother? He'll be home in a few days anyway, and he falls." How do you respond?
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Justify mobilisation
- Two days of bed rest in an older adult produces measurable functional loss, and hospitalisation is itself a risk factor for decline, delirium and loss of independence. Immobility increases the risk of atelectasis, VTE, constipation and pressure injury, all of which prolong admission.
- In acute exacerbations of COPD, early, supervised mobilisation is feasible and does not increase harm when patients are screened and monitored; the risk of a fall is managed by equipment, supervision and progression rather than by keeping him in bed.
- He has had three falls in the past year, so he needs a falls screen and a plan - rollator, footwear, delirium screen, medication review, call bell in reach - not immobility.
How to say it Acknowledge the concern ("You're right that he's at risk of falling - that's exactly why I want him seen by physiotherapy every day rather than left"), state the plan concretely (what we will do, when, what we will monitor), and invite the nurse to join the first session so the handling and stop criteria are shared. Refer to the multidisciplinary team meeting so it is a team plan, not a physiotherapy opinion.
Do not promise the walk will happen today; commit to a plan with review.