Respiratory Disorders

COPD (Chronic Obstructive Pulmonary Disease)

Two diseases under one umbrella — chronic bronchitis and emphysema.

ProblemChronic Bronchitis "Blue Bloater"

Excess mucus production, inflamed airways

ProblemEmphysema "Pink Puffer"

Destruction of alveolar walls → air trapping

Key symptomChronic Bronchitis

Chronic productive cough (≥3 months/year for 2+ years)

Key symptomEmphysema

Severe dyspnea on exertion (barrel chest from hyperinflation)

AppearanceChronic Bronchitis

Overweight, cyanotic ("blue"), edematous

AppearanceEmphysema

Thin, uses pursed-lip breathing, leans forward ("pink")

Nursing Interventions

• Administer bronchodilators BEFORE steroids (open airways first, then reduce inflammation)
• Teach pursed-lip breathing (prolongs exhalation, prevents air trapping)
• Encourage smoking cessation (#1 cause of COPD)
• Position: high-Fowler's or tripod position for breathing ease
• Encourage small, frequent meals (large meals push diaphragm up)
• Encourage flu and pneumonia vaccines
• Monitor for infection (increased sputum production, color change, fever — common trigger for exacerbation)

Asthma

A reversible obstructive disorder — unlike COPD, airway narrowing can be reversed.

Asthma is caused by airway inflammation, bronchoconstriction, and increased mucus production. It is triggered by allergens, exercise, cold air, respiratory infections, smoke, and stress. Key difference from COPD: asthma is reversible and episodic.

Signs & Symptoms of an Asthma Attack

• Wheezing (especially on expiration)
• Dyspnea, chest tightness
• Nonproductive cough (may become productive)
• Tachypnea, tachycardia
• Use of accessory muscles

Medication Order During Attack

Key Teaching

• Rinse mouth after inhaled corticosteroids to prevent oral thrush (candidiasis)
• When using both a bronchodilator and steroid inhaler: use the bronchodilator FIRST (opens airways so steroid can penetrate deeper)
• Use a spacer with MDIs (metered-dose inhalers) for better medication delivery
• Monitor peak flow readings — a decrease indicates worsening
• Avoid known triggers

Pneumonia

Infection of the lung tissue — one of the most common reasons for hospitalization.

Pneumonia is an infection of the lung parenchyma that causes inflammation and fluid/exudate to fill the alveoli, impairing gas exchange. It can be bacterial, viral, or fungal. Community-acquired (CAP) and hospital-acquired (HAP) are the two main categories.

Signs & Symptoms

• Fever, chills, diaphoresis
• Productive cough (rusty/green/yellow sputum)
• Dyspnea, tachypnea
• Pleuritic chest pain (sharp, worse with inspiration)
• Crackles (rales) on auscultation
• Decreased breath sounds over affected area
• Elderly: May present with confusion/altered mental status instead of typical symptoms

Nursing Interventions

• Administer antibiotics as ordered (get sputum culture BEFORE starting antibiotics if possible)
• Encourage coughing and deep breathing, incentive spirometry (IS) every 1–2 hours while awake
• Increase fluid intake (thins secretions) unless fluid restricted
• Semi-Fowler's or high-Fowler's position for breathing ease
• Monitor SpO₂, administer O₂ as needed
• Encourage pneumonia and flu vaccines (prevention!)

Tuberculosis (TB)

Airborne precautions and the difference between latent and active TB.

TB is caused by Mycobacterium tuberculosis, which is transmitted via airborne droplet nuclei. It primarily affects the lungs but can spread to other organs. TB is a reportable disease.

Latent TB vs Active TB

SymptomsLatent TB

NONE — person is asymptomatic

SymptomsActive TB

Persistent cough (>3 weeks), hemoptysis, night sweats, weight loss, fever, fatigue

Contagious?Latent TB

NO

Contagious?Active TB

YES — highly contagious via airborne route

Chest X-rayLatent TB

Normal

Chest X-rayActive TB

Abnormal (infiltrates, cavitations)

TreatmentLatent TB

INH (isoniazid) for 6–9 months

TreatmentActive TB

Multi-drug regimen (RIPE) for 6–12 months

Isolation & Precautions

• AIRBORNE precautions: private negative-pressure room, door closed
• Healthcare workers must wear N95 respirator (regular surgical mask is NOT sufficient)
• Patient wears a regular surgical mask when leaving the room
• Not considered non-infectious until 3 consecutive negative AFB sputum smears (collected 8–24 hours apart, including an early-morning specimen), per facility/public-health policy

RIPE Therapy

• R — Rifampin: turns body fluids orange/red (urine, tears, sweat). Can decrease effectiveness of oral contraceptives.
• I — Isoniazid (INH): monitor for hepatotoxicity (report jaundice, dark urine, fatigue). Give vitamin B6 (pyridoxine) to prevent peripheral neuropathy.
• P — Pyrazinamide: hepatotoxic, increases uric acid (can trigger gout)
• E — Ethambutol: monitor for visual changes (optic neuritis — report blurred vision, color blindness)

Pneumothorax & Chest Tubes

Know the types, what to assess, and chest tube management.

Types of Pneumothorax

• Spontaneous: Occurs without trauma — often in tall, thin males. Air leaks from a ruptured bleb.
• Traumatic: Caused by injury (rib fracture, stab wound, central line insertion)
• Tension pneumothorax: LIFE-THREATENING — air enters pleural space but CANNOT escape. Builds up pressure, shifts mediastinum to the opposite side. Signs: tracheal deviation (away from affected side), absent breath sounds on affected side, JVD, hypotension, tachycardia. Treatment: needle decompression immediately followed by chest tube.

Signs of Pneumothorax

• Sudden sharp chest pain and dyspnea
• Decreased or absent breath sounds on affected side
• Tachycardia, tachypnea
• Subcutaneous emphysema (crackling under skin)

Chest Tube Management (Heavily Tested!)

• Keep the drainage system BELOW the level of the chest at all times
• Monitor for tidaling (water fluctuates with breathing in the water seal chamber) — this is NORMAL and expected. Absence of tidaling may indicate the lung has re-expanded or there's an obstruction.
• Continuous bubbling in the water seal chamber = air leak (abnormal — notify provider)
• Gentle, intermittent bubbling in the suction control chamber = normal
• NEVER clamp a chest tube unless specifically ordered (can cause tension pneumothorax)
• NEVER raise the drainage system above the chest
• Keep petroleum gauze (Vaseline gauze) at the bedside — if the tube accidentally dislodges, cover the site immediately with an occlusive dressing taped on three sides (allows air to escape but prevents air from entering)
• If the drainage system breaks or tips over: place the tube end in a bottle of sterile water (creates a temporary water seal) and call the provider
• Monitor and document drainage: report a sudden increase, bright-red drainage, or >100 mL/hour — per provider order (bright red = hemorrhage)
• Encourage coughing, deep breathing, and incentive spirometry

Oxygen Therapy

Know your delivery devices and flow rates.

Nasal cannula1–6 L/min · 24–44%

Most common, low flow. Humidify if >4 L/min. Patient can eat/talk.

Simple face mask5–8 L/min · 40–60%

Must run at ≥5 L/min to prevent CO₂ rebreathing. Remove to eat.

Non-rebreather mask10–15 L/min · 80–95%

Highest FiO₂ without intubation. Bag must remain inflated. Emergency use.

Venturi mask4–12 L/min · 24–50% precise

Delivers EXACT FiO₂. Best for COPD patients. Color-coded adapters.

Tracheostomy Care

Routine care and emergency management.

• Assess stoma and surrounding skin every shift
• Suction PRN using sterile technique — no longer than 10 seconds per pass (hypoxia risk). Hyperoxygenate with 100% O₂ before and after suctioning.
• Clean inner cannula every 8 hours (or per facility protocol) with hydrogen peroxide, rinse with sterile saline
• Change trach ties when wet or soiled — always keep one finger between tie and neck (prevent skin breakdown and ensure not too tight)
• Keep a spare tracheostomy tube (same size AND one size smaller) AND an obturator at the bedside at ALL times
• If trach is accidentally dislodged in a NEW trach (<72 hours): do NOT reinsert — call the provider, ventilate with bag-valve mask over stoma. If ESTABLISHED trach: reinsert using obturator, then remove obturator immediately.

ABG Basics

The "Tic-Tac-Toe" method for quick ABG interpretation.

Normal ABG Values

pH7.35–7.45

Acidosis (<7.35) vs Alkalosis (>7.45)

PaCO₂35–45 mmHg

Respiratory component. ↑CO₂ = acidosis (retaining acid). ↓CO₂ = alkalosis (blowing off acid).

HCO₃⁻22–26 mEq/L

Metabolic component. ↑HCO₃ = alkalosis. ↓HCO₃ = acidosis.

PaO₂80–100 mmHg

Oxygenation status

3-Step ABG Interpretation

Common ABG Scenarios

Respiratory AcidosispH ↓ · CO₂ ↑ · HCO₃ normal

COPD, respiratory depression, over-sedation

Respiratory AlkalosispH ↑ · CO₂ ↓ · HCO₃ normal

Hyperventilation, anxiety, PE

Metabolic AcidosispH ↓ · CO₂ normal · HCO₃ ↓

DKA, renal failure, diarrhea, lactic acidosis

Metabolic AlkalosispH ↑ · CO₂ normal · HCO₃ ↑

Vomiting, NG suction, excessive antacids, diuretics

Key Respiratory Medications

The respiratory medications most commonly tested on the exam.

Albuterol (ProAir, Ventolin)SABA rescue

Fast-acting bronchodilator. Use FIRST during attack. Side effects: tachycardia, tremors, nervousness.

Ipratropium (Atrovent)Anticholinergic

Bronchodilator for COPD/asthma. Slower onset than albuterol. Often combined with albuterol (DuoNeb).

Fluticasone (Flovent)Inhaled corticosteroid

Maintenance — NOT for acute attacks. RINSE MOUTH after use to prevent oral thrush.

Montelukast (Singulair)Leukotriene modifier

Oral maintenance for asthma. Take at bedtime. Not for acute attacks.

PrednisoneSystemic corticosteroid

Used in exacerbations. Taper dose — never stop abruptly. Monitor glucose, infection risk.

Isoniazid (INH)Anti-TB

Hepatotoxic — monitor LFTs. Give vitamin B6. Avoid alcohol. Treatment: 6–9 months.

RifampinAnti-TB

Turns body fluids orange. Decreases effectiveness of oral contraceptives. Monitor LFTs.

Guaifenesin (Mucinex)Expectorant

Thins secretions. Increase fluid intake for effectiveness. Does not suppress cough.

Frequently Asked Questions

Common student questions on this topic.

Quick-Reference Cheatsheet

Every key point from this guide on a single printable page.