In a 55‑year‑old woman with COPD on long‑acting β2‑agonist and inhaled corticosteroid who presents with worsening symptoms, ankle edema, decreased breath sounds, normal jugular venous pressure, stable vitals except an oxygen saturation of 86 % and an echocardiographic pulmonary artery pressure of 52 mm Hg, what is the most appropriate immediate management?

Immediate Oxygen Therapy is the Most Appropriate Management

For this 55-year-old woman with COPD exacerbation presenting with SpO₂ 86% and pulmonary hypertension (PA pressure 52 mmHg), controlled oxygen therapy targeting 88-92% saturation is the immediate priority, followed by systemic corticosteroids and bronchodilators; antibiotics should be added only if sputum purulence is present.

Rationale for Oxygen as First-Line Therapy

The patient's oxygen saturation of 86% falls below the critical threshold requiring immediate supplemental oxygen. Target SpO₂ 88-92% using controlled oxygen delivery (Venturi mask 24-28% or nasal cannula 1-2 L/min) to prevent CO₂ retention while correcting life-threatening hypoxemia 1, 2. The presence of pulmonary hypertension (52 mmHg; normal ≤20 mmHg) with ankle edema indicates cor pulmonale, which develops secondary to chronic hypoxemia and signals poor prognosis 3. Long-term oxygen therapy is specifically indicated when resting SpO₂ ≤88% or PaO₂ ≤55 mmHg, particularly in the presence of cor pulmonale or pulmonary hypertension 1.

Critical Monitoring Requirements

Obtain arterial blood gas within 60 minutes of initiating oxygen to assess for hypercapnia and acidosis 1, 2, 4. This is mandatory because uncontrolled oxygen can worsen hypercapnic respiratory failure through loss of hypoxic drive, Haldane effect, and ventilation-perfusion mismatch 5. If pH falls below 7.26 with rising PaCO₂, consider non-invasive ventilation 1, 2.

Comprehensive Exacerbation Management

Bronchodilator Therapy (Immediate)

Administer combined short-acting β₂-agonist (salbutamol 2.5-5 mg) plus short-acting anticholinergic (ipratropium 0.25-0.5 mg) via nebulizer every 4-6 hours 1, 2. This combination provides superior bronchodilation lasting 4-6 hours compared to either agent alone 2. Critical: Drive nebulizers with compressed air (not oxygen) if PaCO₂ is elevated or respiratory acidosis develops 1, 4.

Systemic Corticosteroid Protocol (Immediate)

Give oral prednisolone 30-40 mg once daily for exactly 5 days 1, 2. This regimen is as effective as 14-day courses while reducing cumulative steroid exposure by >50%, and it improves lung function, oxygenation, shortens recovery time, and reduces treatment failure by >50% 2. Oral administration is equally effective to intravenous unless the patient cannot tolerate oral intake 2.

Antibiotic Consideration (Conditional)

The question states "sputum appears purulent" is uncertain ("not sure" about salbutamol use suggests incomplete history). Prescribe antibiotics for 5-7 days only when increased sputum purulence is present PLUS either increased dyspnea or increased sputum volume (two of three cardinal symptoms) 2. First-line agents include amoxicillin/clavulanate, amoxicillin, or doxycycline based on local resistance patterns 1, 2. Antibiotics reduce short-term mortality by ~77% and treatment failure by ~53% when appropriately indicated 2.

Why Not Antibiotics or Prednisolone Alone?

While both are important components of exacerbation management, neither addresses the immediate life-threatening hypoxemia (SpO₂ 86%) that requires urgent correction. The presence of cor pulmonale with pulmonary hypertension indicates chronic hypoxemic stress on the right ventricle 3. Reversal of hypoxemia supersedes concerns about CO₂ retention 1, though controlled delivery is essential.

The Cor Pulmonale Context

The ankle edema with elevated PA pressure (52 mmHg) but normal JVP suggests early right ventricular dysfunction from pulmonary hypertension rather than frank right heart failure 3. In hypoxic COPD patients with cor pulmonale, long-term oxygen therapy prolongs life and prevents progression of pulmonary hypertension 6, 3. This patient likely meets criteria for home oxygen therapy after stabilization.

Common Pitfalls to Avoid

• Never give high-flow oxygen (>28% FiO₂ or >4 L/min) without arterial blood gas monitoring 2, 4. This can worsen hypercapnic respiratory failure and increase mortality 5.
• Do not power nebulizers with oxygen if the patient develops hypercapnia 1, 4. Use compressed air with supplemental oxygen via nasal cannula at 1-2 L/min during nebulization 1.
• Do not delay oxygen therapy due to fear of CO₂ retention 1. Hypoxemia causes life-threatening cardiovascular complications including arrhythmias and myocardial ischemia 4.
• Do not continue systemic corticosteroids beyond 5-7 days 1, 2 unless there is a separate indication for long-term therapy.

Post-Stabilization Management

After addressing acute hypoxemia, reassess oxygen requirement within 30-90 days 7. Many patients prescribed oxygen during exacerbations no longer require it after recovery 7. Initiate or optimize long-acting bronchodilator therapy (LAMA preferred) before discharge 2, and schedule pulmonary rehabilitation within 3 weeks post-discharge to reduce readmissions 2.