In a severe COPD exacerbation requiring hospitalization, which of the following best describes the initial management including oxygen target and key therapies?

• A. Supplemental oxygen to target SpO2 88–92%, systemic corticosteroids, short-acting bronchodilators (nebulized SABA with anticholinergic), antibiotics if infection suspected, and noninvasive ventilation if respiratory failure persists.
• B. Supplemental oxygen to target SpO2 96–100%, long-acting bronchodilators only, no steroids, and no antibiotics.
• C. Oxygen to target SpO2 88–92% with diuretics and sedatives.
• D. Immediate intubation and mechanical ventilation without NIV consideration.

Answer: (A)

In a severe COPD flare, the key is to support ventilation and soothe airway obstruction while avoiding worsening CO2 retention. Oxygen should be given carefully, targeting a SpO2 of about 88–92% rather than trying to push toward normal levels; giving too much oxygen can raise CO2 levels and worsen acidosis in COPD patients. Along with oxygen, give systemic corticosteroids to shorten the course of the exacerbation and speed recovery, and use short-acting bronchodilators such as a nebulized beta-agonist with an anticholinergic to rapidly relieve bronchospasm. If there is suspicion of bacterial infection, start antibiotics. If the patient has persistent respiratory failure or hypercapnia despite initial therapy, noninvasive ventilation should be initiated to support breathing and reduce the need for intubation; if noninvasive ventilation fails or the patient cannot protect their airway, proceed to invasive ventilation.

Options that suggest a higher oxygen target, or rely only on long-acting bronchodilators without steroids or antibiotics, omit essential acute management steps. Diuretics and sedatives aren’t standard initial management for this situation, and rushing to immediate intubation without attempting noninvasive ventilation misses an appropriate escalation path.