Scenario — COPD Exacerbation — Elderly Male

intermediate Respiratory · Elderly · 75yr · male

Patient Information

Dispatch	A 75YO male has presented to the FAP at the Perth Royal Show reporting significant difficulty breathing. (Reg Hollingsworth)
Patient	Reg Hollingsworth — 75yr (75kg)
Incident History	Pt states he has been walking around the showgrounds for approximately 2 hours and his breathing has been getting progressively worse. Pt is a known COPD patient and uses home oxygen at night.
Emergency Contact	Maureen Hollingsworth (Wife) — 0412 883 441

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstruction. Nil stridor. Able to speak in 3–4 word sentences.
Breathing	Laboured. Audible expiratory wheeze bilaterally. Accessory muscle use present. Tachypnoeic. SpO2 84% on room air. RR 26.
Circulation	Radial pulse rapid and regular. Skin warm, mild peripheral cyanosis of fingertips. Nil active bleeding.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Mild anxiety noted.
Exposure	Barrel-chested appearance. No rashes or visible trauma. Ankles mildly oedematous bilaterally.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	84% (RA)	Moderate	26	108	148/88	<2s	15	4 4 ++	37.1	6.4 mmol/L	2
10 mins	91% (O2 NC 2L/min)	Mild	20	98	142/84	<2s	15	4 4 ++	37.1	6.4 mmol/L	1

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD), precipitated by physical exertion and likely allergen/irritant exposure at the showgrounds.

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is applied via non-rebreather mask at high flow without titration, SpO2 rises to 97% — patient becomes more drowsy, RR drops to 12, GCS drops to 13. Facilitator prompts: 'The patient is becoming increasingly drowsy. What is your concern?')
! (If oxygen is not applied within 3 minutes of assessment, SpO2 drops to 80% on room air and patient becomes increasingly agitated and cyanosed.)
! (If trainee does not ask about home oxygen or regular medications, facilitator prompts the patient to mention 'I normally use oxygen at night' only if directly asked about usual health.)
! (If trainee targets SpO2 above 94% and applies high-flow oxygen without reassessment, the patient's respiratory drive reduces — prompting discussion of controlled oxygen therapy in COPD.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm patent airway, identify laboured breathing and wheeze, assess circulation and GCS.
3. Position patient sitting upright or in a position of comfort — do NOT lay patient flat.
4. Apply pulse oximetry and obtain initial SpO2 (84% RA).
5. Administer controlled oxygen therapy — commence via nasal cannula at 2 L/min (FiO2 approximately 28%), titrating to target SpO2 of 88–92%. Do NOT use non-rebreather mask without specific clinical justification.
6. Obtain IMISTAMBO history including medications, COPD diagnosis, home oxygen use, and prior salbutamol use at scene.
7. Reassess SpO2, RR, and work of breathing after oxygen application — adjust flow rate as needed to maintain 88–92%.
8. Record full observations including BP, pulse, RR, GCS, SpO2, BGL, and pain score.
9. Recognise known cardiac comorbidity (mild cardiac failure) — monitor for signs of fluid overload or clinical deterioration.
10. Do NOT administer salbutamol — salbutamol administration for COPD is Intermediate Care scope and above; EHS Primary Care scope is limited to controlled oxygen and positioning.
11. Reassess observations at 10 minutes — confirm improvement in SpO2 to 88–92% range and reduced work of breathing.
12. Arrange Priority 1 transport with ambulance — pre-notify receiving facility of time-critical COPD exacerbation with known cardiac comorbidity.
13. Maintain continuous patient monitoring and reassessment during transport preparation.
14. Scenario ends on arrival of ambulance and IMISTAMBO handover.
15. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Oxygen Delivery · Dyspnoea & Respiratory Distress · Primary Survey · Pulse Oximetry

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Signs/Symptoms	Progressive shortness of breath, wheeze, increased sputum production over the past 2 days. Mild chest tightness. Ankle swelling noted by patient as 'a bit worse than usual'.
Allergies	Nil known drug allergies.
Medications	Tiotropium inhaler (Spiriva) once daily, salbutamol MDI as needed, prednisolone 5 mg daily (long-term), home oxygen 2 L/min nocturnal.
Pertinent History	Known COPD — diagnosed 12 years ago, ex-smoker (40 pack-year history, quit 10 years ago). Known mild cardiac failure — on frusemide 40 mg daily. Hypertension — on perindopril 5 mg daily. No recent respiratory infections reported.
Last Oral Intake	Light breakfast approximately 3 hours ago. Adequate fluid intake.
Events Leading	Pt attended the Perth Royal Show with his wife. After walking around animal exhibits for approximately 2 hours, his breathing progressively worsened. His wife walked him to the FAP.
Treatment Prior	Used his own salbutamol MDI twice before coming to the FAP approximately 30 minutes ago with minimal relief.

Onset	Gradual worsening over 2 days with acute deterioration after walking around the showgrounds for approximately 2 hours today.
Pain	Mild chest tightness 2/10. Non-exertional, diffuse, not sharp.
Quality	Heaviness and tightness in chest. Feeling of 'not being able to get enough air out'.
Radiates	Nil radiation.
Severity	2/10 chest tightness. Shortness of breath 8/10.