Early recognition and rapid intervention lead to a good outcome.

MR. ROBERT MARTINEZ*, a 75-year-old man with a history of chronic obstructive pulmonary disease (COPD), hypertension, and a 20-pack-year smoking history, is transferred from the ED to a med–surg unit for continued monitoring after a COPD exacerbation. The provider orders 3 liters per minute (LPM) of supplemental oxygen via nasal cannula. After 4 hours on the unit, Mr. Martinez’s assigned nurse, Pat, and a training nurse, Taylor, notice changes in his condition.

Initial assessment

Pat observes Mr. Martinez’s increasing restlessness and confusion. At assessment, his SpO₂ has dropped to 84%, RR has increased to 31 breaths per minute, and HR has risen to 108 bpm. Recognizing the significance of these findings, Pat and Taylor conduct a focused respiratory assessment, including auscultation, palpation, and inspection. They auscultate generalized wheezing throughout his lung fields, a classic sign of airway constriction in patients with COPD. Upon inspection they note accessory muscle use, indicating increased work of breathing.

Understanding the need for timely intervention, Pat contacts respiratory therapy to initiate a bronchodilator breathing treatment and notifies the provider, who orders a Venturi mask set at 50% FiO₂ to maintain SpO₂ between 89% and 92%, continuous SpO₂ monitoring, and arterial blood gases.

Intervention and critical thinking

Pat guides Taylor through the steps of switching Mr. Martinez from a nasal cannula to a Venturi mask. She explains the importance of delivering the correct O₂ concentration to reduce the risk of hypercapnia, a common concern in patients with advanced COPD. Pat asks Taylor to place the mask on Mr. Martinez while she checks a call light from another patient.

After the respiratory therapist administers the bronchodilator breathing treatment, Taylor resumes oxygen delivery via the Venturi mask as ordered. A follow-up inspection reveals continued accessory muscle use, while auscultation reveals reduced wheezing, indicating reduced obstruction and improved air flow. However, 10 minutes later, the patient’s SpO₂ remains low at 86%, and his respiratory distress hasn’t significantly improved. Pat reassesses the situation and discovers that the Venturi mask is still connected to a flowmeter set at 3 LPM, insufficient for the 50% FiO₂ required by the mask. Unlike nasal cannulas, which deliver variable oxygen concentrations, Venturi masks require a specific flow rate to maintain their fixed O₂ concentration; a 50% FiO₂ typically requires a 12 to 15 LPM flow rate. Pat adjusts the flowmeter. Within minutes, the patient’s SpO₂ rises to 92%, his breathing eases, and he reports feeling better.

Outcome and lessons learned

Mr. Martinez’s condition stabilizes over the following hours. This case highlights the importance of thorough assessment, rapid recognition of patient deterioration, and careful attention to O₂ delivery settings in patients with COPD. It also underscores the critical role of nurse mentorship in training new staff to ensure they develop the clinical judgment and confidence necessary to respond effectively to patient emergencies.

Patient and staff education

For patients with COPD (a progressive lung disease that limits airflow), maintaining precise O₂ delivery is critical. Venturi masks provide a controlled, fixed concentration of O₂, but they require the correct flowmeter settings to function properly. Nurses should always verify the required LPM settings on the Venturi device itself to avoid potentially dangerous hypoxia or hypercapnia. Ongoing education about the use of different O₂ delivery devices helps to ensure patient safety and positive outcomes.

*Name is fictitious.

Herica Torres Alzate is an assistant professor at University of South Florida in Tampa.

American Nurse Journal. 2026; 21(2). Doi: 10.51256/ANJ022648

References

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Khan KS, Jawaid S, Memon UA, et al. Management of chronic obstructive pulmonary disease (COPD) exacerbations in hospitalized patients from admission to discharge: A comprehensive review of therapeutic interventions. Cureus. 2023;15(8): e43694. doi:10.7759/cureus.43694

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Keywords: chronic obstructive pulmonary disease, COPD, oxygen management, mentoring