9.3 Respiratory Alterations

Respiratory Alterations

Airway and breathing problems are top NCLEX priority because they map directly to the ABCs. When a respiratory item asks for the first action, the answer almost always addresses oxygenation or airway before anything else.

Recognizing Respiratory Distress

• Tachypnea (rate >20/min) and dyspnea — earliest objective changes
• Accessory muscle use, nasal flaring, retractions — increased work of breathing
• Restlessness, confusion, anxiety — early hypoxia (a frequently missed answer)
• Cyanosis — a late sign; do not wait for it
• Abnormal sounds: crackles (fluid), wheezes (narrowing), diminished/absent (consolidation, effusion, pneumothorax)

COPD: Chronic Bronchitis vs. Emphysema

COPD is largely irreversible airflow limitation, unlike reversible asthma.

Oxygen safety: Patients with chronic CO₂ retention may breathe on a hypoxic drive. Use low-flow oxygen (1–2 L/min nasal cannula) and target SpO₂ 88–92%. High-flow oxygen can blunt the drive and cause CO₂ narcosis. Other care: bronchodilators (albuterol, tiotropium), inhaled corticosteroids for maintenance, pulmonary rehab, and smoking cessation — the single most effective intervention.

Asthma

Asthma is reversible bronchoconstriction with inflammation and mucus. Triggers include allergens, infection, exercise, cold air, smoke, and stress.

Peak flow zones: Green 80–100% of personal best (good control), Yellow 50–79% (use rescue inhaler, caution), Red <50% (emergency). When teaching combined inhalers, give the bronchodilator first, wait, then the steroid, and rinse the mouth after steroids to prevent thrush.

Pneumonia

Infection of the lung parenchyma causing consolidation.

• Community-acquired: often Streptococcus pneumoniae; rust-colored sputum
• Hospital-acquired: ≥48 hours after admission; MRSA, Pseudomonas
• Aspiration: anaerobes from oral/gastric contents

Signs: fever, chills, productive cough, pleuritic chest pain, crackles, elevated WBC. Nursing: antibiotics on time (after cultures), coughing/deep breathing, incentive spirometry, hydration to thin secretions, position for lung expansion, monitor SpO₂.

Pulmonary Embolism

A clot — usually a dislodged DVT — lodges in the pulmonary artery. Risk follows Virchow's triad: venous stasis (immobility, surgery, long travel), vessel injury, and hypercoagulability (cancer, pregnancy, oral contraceptives).

Classic presentation: sudden dyspnea, sharp pleuritic chest pain, tachycardia, tachypnea, hypoxia, anxiety/impending doom, and possibly unilateral leg swelling. Treatment: oxygen, anticoagulation (heparin bridging to warfarin or a direct oral anticoagulant), thrombolytics for massive PE, and an IVC filter if anticoagulation is contraindicated. Prevention is heavily tested: early ambulation, sequential compression devices, and prophylactic anticoagulation.

Tuberculosis

Mycobacterium tuberculosis spreads by airborne droplet nuclei, not by touching surfaces, and needs prolonged close contact.

Precautions: negative-pressure (airborne isolation) room, N95 respirator for staff, surgical mask on the patient during transport, continued until three negative sputum AFB smears. Teach strict adherence to the full multi-drug course — incomplete therapy breeds drug resistance.

Chest Tubes

For pneumothorax, hemothorax, effusion, or post-thoracic surgery. Keep the drainage system below chest level, maintain the water seal (~2 cm), and expect tidaling (fluid rising and falling with respiration) — its absence may mean re-expansion or an obstruction. Continuous bubbling in the water-seal chamber means an air leak; intermittent bubbling with coughing can be normal. Report drainage >100 mL/hr. Never routinely clamp the tube; keep an occlusive (petroleum) dressing at the bedside for accidental dislodgement.

Oxygen Delivery Devices

Matching the device to the patient is a frequent test point. Know the rough flow rates and the fraction of inspired oxygen each provides.

• Nasal cannula: 1–6 L/min, ~24–44% oxygen; comfortable, lets the patient eat and talk; the COPD workhorse at 1–2 L/min.
• Simple face mask: 5–10 L/min, ~40–60%; needs a minimum 5 L/min to flush exhaled CO₂.
• Non-rebreather mask: 10–15 L/min, up to ~90%+; reservoir bag must stay inflated; used for acute, severe hypoxia.
• Venturi mask: delivers a precise, fixed oxygen percentage; the preferred device when a COPD patient needs controlled, titrated oxygen.

Humidify oxygen above 4 L/min to protect mucosa, post "oxygen in use" signage, and keep open flames and electric razors away from the source.

Tracheostomy and Suctioning Safety

Suctioning is within the LPN/VN scope and shows up regularly. Hyperoxygenate before suctioning, apply suction only on withdrawal, limit each pass to 10–15 seconds, and allow recovery between passes. Suctioning that lasts too long causes hypoxia and can trigger vagal bradycardia. Keep a spare tracheostomy tube (one same size, one smaller) and an obturator at the bedside for emergency reinsertion.

Prioritizing Respiratory Patients

When two respiratory patients compete for attention, the exam wants you to choose the one whose airway or oxygenation is most threatened right now. A new-onset stridor, a silent chest in an asthmatic (no wheezing because almost no air is moving), an SpO₂ falling despite oxygen, or rising confusion all outrank a stable patient with chronic dyspnea. Restlessness and confusion are early hypoxia and must never be dismissed as anxiety — sedating such a patient is a classic wrong answer.