((If oxygen is administered at high flow — e.g. NRB 15L/min — without titration: patient becomes drowsy after 5 minutes, GCS drops to 13 (E3V4M6), RR decreases to 10/min — facilitator prompts 'The patient looks sleepy and is breathing more slowly — what do you want to do about their oxygen?'))

((If SpO2 target is not titrated to 88–92% and high-flow oxygen is continued: patient begins to look increasingly lethargic at 10 minutes and respiratory rate falls to 8/min — facilitator states 'The patient is now barely breathing — what is your next action?'))

((If the trainee does not position the patient upright: patient states 'I can't breathe like this, I need to sit up' — facilitator prompts 'The patient is clearly more distressed in their current position.'))

((If the trainee attempts to administer salbutamol via nebuliser: facilitator reminds 'EHS are not authorised to administer nebulised medications — what alternative route is available to you?'))

((If the trainee does not ask about medications and misses that the patient has already used his own Ventolin three times: facilitator prompts 'You notice a Ventolin puffer in the patient's shirt pocket — do you want to ask him about it?'))

This patient is suffering from an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD), precipitated by cold air exposure and a likely infective exacerbation given 2 days of increased sputum production.

• Ensure personal safety and don appropriate PPE including gloves.
• Conduct Primary Survey — confirm patent airway, identify moderate respiratory distress, detect SpO2 85% on room air.
• Position patient upright or in position of comfort immediately — do not lay the patient flat.
• Apply pulse oximetry monitoring and conduct Vital Sign Survey.
• Administer oxygen via nasal cannula at 1–2 L/min — titrate carefully to achieve SpO2 target of 88–92% for COPD patient. Do NOT use high-flow oxygen or non-rebreather mask without clinical justification.
• Reassess SpO2 every 2–3 minutes during oxygen titration — if target not achieved on nasal cannula, cautiously increase flow rate by 1 L/min increments up to a maximum of 4 L/min before considering simple face mask at 5 L/min.
• Conduct IMISTAMBO-style history: confirm known COPD, 2 days of increased sputum, prior salbutamol use, current medications (Spiriva, Ventolin), nil known drug allergies.
• Assist patient to administer their own salbutamol (Ventolin) via MDI with spacer — 4–12 inhalations (400–1200 microg) via Space Chamber. Note: EHS may assist patient to use their own inhaler as per CPG.
• Monitor patient response to oxygen therapy and salbutamol — repeat full vital signs at 10 minutes.
• Record full observations every 10 minutes (or 5 minutes if patient appears time critical).
• Recognise time-critical indicators: SpO2 not improving to 88–92% with titrated oxygen, increasing respiratory distress, decreasing GCS — escalate to Priority 1 transport with pre-notification to receiving hospital.
• Arrange transport to hospital — this patient has not fully responded to prior self-administered bronchodilator and requires advanced care (IV access, formal salbutamol, possible ipratropium).
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Oxygen · Salbutamol Sulphate · MDI & Space Chamber · Pulse Oximetry · Primary Survey