Key Takeaways
- COPD patients may have hypoxic respiratory drive; use low-flow oxygen (1-2 L/min) and monitor closely
- Pursed-lip breathing helps COPD patients exhale trapped air and reduce air trapping
- COPD exacerbation treatment: bronchodilators (albuterol), corticosteroids, antibiotics if infection present
- Pneumonia presents with fever, productive cough, crackles, and consolidation on chest X-ray
- Encourage fluids in pneumonia to thin secretions; incentive spirometry and position changes prevent complications
Last updated: January 2026
Respiratory Conditions
Respiratory conditions significantly impact oxygenation and ventilation. Nurses must understand the pathophysiology of these conditions to provide appropriate care and prevent life-threatening complications.
Chronic Obstructive Pulmonary Disease (COPD)
COPD is a chronic, progressive lung disease characterized by persistent airflow limitation. It includes chronic bronchitis and emphysema.
Pathophysiology
Chronic Bronchitis:
- Inflammation of bronchial tubes
- Excessive mucus production
- "Blue bloater" appearance (cyanosis, edema)
Emphysema:
- Destruction of alveolar walls
- Loss of elastic recoil
- Air trapping
- "Pink puffer" appearance (pursed-lip breathing, barrel chest)
Risk Factors
- Smoking (primary cause - 85-90% of cases)
- Alpha-1 antitrypsin deficiency
- Occupational dust and chemical exposure
- Air pollution
- Recurrent respiratory infections
Clinical Manifestations
| Finding | Description |
|---|---|
| Dyspnea | Progressive shortness of breath, especially with exertion |
| Chronic Cough | Productive, especially in chronic bronchitis |
| Barrel Chest | Increased AP diameter from air trapping |
| Prolonged Expiration | Difficulty exhaling due to airway obstruction |
| Use of Accessory Muscles | Neck and shoulder muscles during breathing |
| Pursed-Lip Breathing | Compensatory technique to exhale CO2 |
| Tripod Position | Leaning forward with hands on knees |
| Wheezing | High-pitched sounds on expiration |
| Clubbing | Chronic hypoxia indicator |
The Hypoxic Drive Concept
Critical Concept: In advanced COPD, patients may lose their normal respiratory drive (response to high CO2) and instead rely on low oxygen levels to stimulate breathing.
Implications for Oxygen Therapy:
- Use low-flow oxygen (1-2 L/min via nasal cannula)
- Target SpO2: 88-92% (not 100%)
- High-flow oxygen may suppress respiratory drive
- Monitor closely for hypoventilation and CO2 retention
- Watch for signs of CO2 narcosis: confusion, lethargy, decreased LOC
COPD Medications
Bronchodilators:
| Type | Examples | Action |
|---|---|---|
| Short-acting beta-agonists (SABA) | Albuterol | Rapid relief, "rescue" inhaler |
| Long-acting beta-agonists (LABA) | Salmeterol, formoterol | Maintenance, use twice daily |
| Anticholinergics (SAMA/LAMA) | Ipratropium, tiotropium | Reduce secretions, bronchodilation |
Anti-inflammatory:
- Inhaled corticosteroids (ICS): Fluticasone, budesonide
- Oral corticosteroids for exacerbations
Combination Inhalers:
- LABA + ICS
- LABA + LAMA
Nursing Interventions for COPD
Breathing Techniques:
- Pursed-lip breathing: Inhale through nose, exhale slowly through pursed lips (like blowing out a candle)
- Prolongs exhalation, prevents airway collapse, helps exhale trapped CO2
- Diaphragmatic breathing: Focus on belly rising with inspiration
Positioning:
- High Fowler's or orthopneic position (leaning forward)
- Reduces work of breathing
- Allows diaphragm to move freely
Energy Conservation:
- Rest periods between activities
- Pace activities throughout the day
- Use assistive devices as needed
Infection Prevention:
- Annual influenza vaccine
- Pneumococcal vaccine
- Avoid crowds during flu season
- Hand hygiene
COPD Exacerbation
An acute worsening of symptoms, often triggered by infection.
Signs of Exacerbation
- Increased dyspnea
- Change in sputum (volume, color, thickness)
- Increased cough
- Fever
- Confusion (hypoxia or CO2 retention)
Treatment
- Bronchodilators: Albuterol nebulizer treatments
- Corticosteroids: Prednisone 40-60 mg daily for 5-7 days
- Antibiotics: If bacterial infection suspected (purulent sputum)
- Oxygen: Titrate to maintain SpO2 88-92%
- BiPAP: For respiratory failure to avoid intubation
Pneumonia
Pneumonia is an acute infection of the lung parenchyma causing inflammation and consolidation.
Types of Pneumonia
| Type | Description |
|---|---|
| Community-Acquired (CAP) | Acquired outside healthcare settings |
| Hospital-Acquired (HAP) | Develops > 48 hours after admission |
| Ventilator-Associated (VAP) | Develops > 48 hours after intubation |
| Aspiration | Inhalation of oral/gastric contents |
Common Pathogens
| Setting | Organisms |
|---|---|
| CAP | Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma |
| HAP/VAP | Pseudomonas, MRSA, Gram-negative bacteria |
| Aspiration | Mixed anaerobes, Gram-negative |
| Immunocompromised | Pneumocystis jiroveci, fungal organisms |
Clinical Manifestations
Typical Pneumonia:
- Fever, chills
- Productive cough (purulent, rust-colored, or green sputum)
- Pleuritic chest pain (sharp, worse with inspiration)
- Tachypnea, tachycardia
- Crackles on auscultation
- Diminished breath sounds over affected area
- Dullness to percussion (consolidation)
Atypical Pneumonia:
- Gradual onset
- Dry, nonproductive cough
- Lower fever
- Headache, myalgias
- Often caused by Mycoplasma, Chlamydia, or Legionella
Diagnostic Tests
| Test | Purpose |
|---|---|
| Chest X-ray | Confirms infiltrate/consolidation |
| Sputum Culture | Identifies organism (obtain before antibiotics if possible) |
| Blood Cultures | For bacteremia detection |
| CBC | Elevated WBC indicates infection |
| Procalcitonin | Elevated in bacterial pneumonia |
| Pulse Oximetry/ABG | Assess oxygenation |
Treatment of Pneumonia
Antibiotics:
- Empiric therapy started based on likely pathogens
- Adjust based on culture results
- CAP: Macrolide (azithromycin) or respiratory fluoroquinolone
- HAP/VAP: Broader coverage including anti-pseudomonal agents
Supportive Care:
- Oxygen therapy to maintain SpO2 > 92%
- IV fluids if dehydrated
- Antipyretics for fever
- Adequate rest
Nursing Interventions for Pneumonia
Airway Clearance:
- Encourage fluids (2-3 L/day if not contraindicated) to thin secretions
- Humidified oxygen
- Chest physiotherapy if ordered
- Incentive spirometry every 1-2 hours while awake
- Splint chest when coughing
Positioning:
- Semi-Fowler's or high Fowler's position
- Turn every 2 hours
- "Good lung down" for unilateral pneumonia (promotes V/Q matching)
Prevention of Complications:
- Early mobilization
- DVT prophylaxis
- Hand hygiene and isolation if indicated
- Monitor for sepsis development
Comparison: COPD vs. Pneumonia
| Feature | COPD | Pneumonia |
|---|---|---|
| Type | Chronic condition | Acute infection |
| Onset | Progressive | Acute |
| Fever | Usually absent unless exacerbation | Usually present |
| Cough | Chronic | Acute, productive |
| Lung Sounds | Wheezes, diminished | Crackles, bronchial sounds |
| Chest X-ray | Hyperinflation | Infiltrate/consolidation |
| O2 Therapy | Low flow (1-2 L/min) | As needed for SpO2 > 92% |
Key Points for the NCLEX
- COPD: Low-flow oxygen (1-2 L/min), target SpO2 88-92%
- Pursed-lip breathing helps exhale trapped CO2 in COPD
- Pneumonia: Encourage fluids to thin secretions
- Incentive spirometry prevents atelectasis and complications
- Crackles = pneumonia (fluid in alveoli)
- Wheezes = COPD/asthma (airway narrowing)
- Obtain sputum culture before antibiotics when possible
- "Good lung down" positioning for unilateral pneumonia
Test Your Knowledge
A patient with severe COPD has an SpO2 of 86% on room air. What is the appropriate oxygen delivery method?
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D
Test Your Knowledge
Which breathing technique should the nurse teach a patient with COPD to help with exhalation?
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B
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D
Test Your Knowledge
A patient with pneumonia has thick, tenacious secretions. Which intervention is most important?
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D