Simulated Patient Scenario

COPD Exacerbation

Scenario Details

Scenario: Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)

Simulated Patient: 67-year-old Male

Actor/Actress: Student Actor (Patient)

MDT Information

Urgent Response - Difficulty Breathing
67-year-old male, known COPD
Increased shortness of breath and cough
Patient sounds very breathless on phone
Patient is conscious and alert
Location: Home address, patient lives alone

On Arrival

You arrive at a small house. The front door is unlocked. You find the patient, a 67-year-old male, sitting in a chair in the living room, leaning forward with hands on his knees (tripod position). He appears anxious and is using significant effort to breathe, with visible accessory muscle use. He has pursed-lip breathing and audible expiratory wheezing. His skin appears slightly grey/cyanotic around the lips. A home nebuliser machine is on a table nearby.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Alert male in severe respiratory distress, tachypnoeic, using accessory muscles, audible wheeze, possible cyanosis.
Response	Alert, anxious, speaks only in single words or short phrases. (AVPU = A)
Airway	Clear and self-maintaining, but audible wheeze present.
Breathing	Severe respiratory distress: Marked tachypnoea, significant accessory muscle use (sternocleidomastoid, intercostals), pursed-lip breathing, prolonged expiration, audible wheeze.
Circulation	Skin pale/greyish tinge, warm centrally. Tachycardic. Peripheral pulses may be difficult to feel due to position/distress.
Disability	Alert (GCS 15), anxious.
Exposure/Environment	Indoor home environment. Note presence of inhalers, nebuliser, home oxygen (if any).

Secondary Survey and Simulation Progression

History (obtained from patient - difficult due to breathlessness)

Allergies	NKDA
Medications	Tiotropium (Spiriva) HandiHaler daily, Seretide Accuhaler BD, Salbutamol MDI PRN, Home nebuliser with Salbutamol/Ipratropium solutions. Occasional Prednisolone course for exacerbations.
Past Medical History	Severe COPD (diagnosed 15+ years ago). Ex-smoker (quit 5 years ago, 40 pack-year history). Hypertension. Frequent exacerbations requiring hospitalisation (2 admissions in last 12 months). Not on home oxygen.
Last Oral Intake	Poor appetite, only had tea this morning.
Events Preceding	Patient reports increased cough with yellow/green sputum and worsening shortness of breath over the past 3 days. Used Salbutamol inhaler frequently yesterday and today with little relief. Used home nebuliser (Salbutamol/Ipratropium) about 1 hour ago, also with minimal effect. Breathlessness became much worse in the last hour, prompting call. Denies chest pain, fever explicitly but feels generally unwell.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	32 (Tachypnoeic)
Lung Sounds (L/R)	Widespread polyphonic expiratory wheeze bilaterally. Reduced air entry throughout. Possible coarse crackles at bases.
SpO2 (%)	86% (Room Air)
EtCO2 (mmHg)	55 mmHg (High - indicates hypercapnia/respiratory acidosis)
Pulse Rate (/min.)	115, regular
CRT (sec.)	2-3 sec
ECG rhythm	Sinus Tachycardia
12-lead ECG	Sinus Tachycardia. May show signs of right heart strain (P pulmonale, RAD, RBBB) if chronic cor pulmonale present. Rule out ischaemia.
BP (mmHg)	150/90 (May be elevated due to hypoxia/stress)
Skin	Pale, slightly grey/cyanotic lips, warm centrally, possibly cool peripheries.
Pain (/10)	Denies pain, reports severe breathlessness.
GCS (/15: E,V,M)	14/15 (E4, V4 - confused/single words, M6) - May deteriorate with worsening hypercapnia.
BGL (mmol/L)	7.0 (Can be elevated due to stress/steroids).
Pupils (mmL/mmR)	Equal and Reactive (PERL).
Temp. (°C)	37.5 (May have low-grade fever if infective trigger).

Physical Examination

General Appearance: Anxious, severe respiratory distress, tripod position, pursed-lip breathing, speaking single words. Barrel chest appearance.
Respiratory: Marked accessory muscle use. Tachypnoea. Audible wheeze. Diffuse expiratory wheeze on auscultation, prolonged expiratory phase, reduced air entry. Possible basal crackles. Percussion note may be hyperresonant.
Cardiovascular: Tachycardia. BP may be elevated. JVD may be present if cor pulmonale.
Neurological: Alert but potentially becoming drowsy/confused due to hypercapnia (GCS 14).
Skin: Central/peripheral cyanosis may be present.

Assessment and Treatment

Appropriate Management Focus

Primary Survey (ABCDE) & Severity Assessment: Recognize severe COPD exacerbation with hypoxia and likely hypercapnia. Risk of respiratory failure.
Oxygen Therapy: **Administer controlled/titrated oxygen.** Start with low-moderate flow via nasal prongs or simple face mask aiming for target SpO2 range of **88-92%** (per local guidelines for known COPD/risk of hypercapnia). Avoid high concentrations unless patient is critically hypoxic or peri-arrest. Monitor SpO2 and respiratory status closely.
Bronchodilator Therapy:**

Administer **Salbutamol** and **Ipratropium Bromide** via nebuliser (driven by air if possible, or oxygen at appropriate flow rate to maintain target SpO2). Use doses per local protocol (e.g., Salbutamol 5mg, Ipratropium 500mcg).

Repeat nebulisers frequently (e.g., back-to-back or every 20 mins) based on clinical response.

Corticosteroids: Administer early corticosteroids per local protocol (e.g., IV Hydrocortisone or oral Prednisolone if patient can tolerate/swallow safely).

Positioning: Allow patient to maintain position of comfort (usually sitting upright, leaning forward).

Monitoring: Continuous SpO2, ECG, and EtCO2 (if available - monitor trend). Frequent reassessment of respiratory status (work of breathing, RR, air entry, wheeze, conscious state), HR, BP.

Consider Non-Invasive Ventilation (NIV - CPAP/BiPAP): Prehospital NIV may be indicated for severe exacerbations with respiratory acidosis/hypercapnia if available and crew are trained/credentialed per local protocols.

IV Access: Establish IV access.

Transport: Urgent transport to the nearest appropriate Emergency Department. Pre-notify receiving hospital (Severe COPD exacerbation, hypoxic, hypercapnic, treatments given, response, ?NIV candidate).

Teamwork & Communication: Calm, reassuring approach. Explain interventions. Clear handover focusing on severity, treatments, and response.

Debrief Focus Points

Recognizing signs/symptoms of severe COPD exacerbation.

Assessing severity and identifying potential respiratory failure (hypoxia, hypercapnia, exhaustion).

Principles of controlled oxygen therapy in COPD (target SpO2 88-92%).

Appropriate administration of bronchodilators (Salbutamol, Ipratropium).

Role and timing of corticosteroids.

Indications and considerations for prehospital NIV (if applicable).

Monitoring for deterioration (worsening WOB, drowsiness, rising EtCO2).

Differentiating COPD exacerbation from other causes of dyspnoea (e.g., heart failure, PE, pneumonia).