Key Takeaways
- COPD patients: target SpO2 88-92% to avoid suppressing hypoxic drive
- Continuous bubbling in chest tube water seal indicates an air leak
- Active TB requires airborne precautions with negative pressure room and N95 respirators
- PE presents with sudden dyspnea, pleuritic chest pain, and hypoxia
- Asthma is reversible; COPD is irreversible airway obstruction
Respiratory Alterations
Respiratory conditions can rapidly become life-threatening. LPN/VNs must recognize respiratory distress, understand common respiratory disorders, and implement appropriate interventions.
Signs of Respiratory Distress
| Sign | Description |
|---|---|
| Dyspnea | Shortness of breath, labored breathing |
| Tachypnea | Respiratory rate > 20/min |
| Use of Accessory Muscles | Neck, intercostal, abdominal muscles working to breathe |
| Nasal Flaring | Widening of nostrils with each breath |
| Retractions | Visible pulling in of chest wall |
| Cyanosis | Blue discoloration of lips, nail beds (late sign) |
| Altered Mental Status | Confusion, restlessness (sign of hypoxia) |
| Abnormal Breath Sounds | Crackles, wheezes, diminished sounds |
Chronic Obstructive Pulmonary Disease (COPD)
COPD includes chronic bronchitis and emphysema, characterized by irreversible airflow obstruction.
| Feature | Chronic Bronchitis | Emphysema |
|---|---|---|
| Nickname | "Blue bloater" | "Pink puffer" |
| Pathology | Excessive mucus, airway inflammation | Alveolar destruction, loss of elasticity |
| Cough | Productive, chronic | Minimal |
| Appearance | Cyanotic, overweight | Thin, barrel chest |
| Dyspnea | During exertion | Progressive, at rest |
COPD Management:
- Bronchodilators: Short and long-acting (albuterol, tiotropium)
- Corticosteroids: Inhaled for maintenance, systemic for exacerbations
- Oxygen Therapy: Low-flow (1-2 L/min) to maintain SpO2 88-92%
- Pulmonary Rehabilitation: Breathing exercises, energy conservation
- Smoking Cessation: Most important intervention
COPD Oxygen Precaution:
- Patients with chronic CO2 retention breathe based on hypoxic drive
- High-flow oxygen may suppress respiratory drive
- Use low-flow oxygen; maintain SpO2 88-92%
Asthma
Asthma is a reversible airway obstruction caused by inflammation, bronchoconstriction, and increased mucus production.
Asthma Triggers:
- Allergens (dust, pollen, pet dander)
- Respiratory infections
- Exercise
- Cold air
- Irritants (smoke, chemicals)
- Stress/emotions
Asthma Management:
| Category | Medications | Purpose |
|---|---|---|
| Quick Relief (Rescue) | SABA (albuterol) | Acute bronchospasm relief |
| Controller (Maintenance) | ICS (fluticasone), LABA (salmeterol), leukotriene modifiers | Prevent attacks, reduce inflammation |
| Severe Attacks | Systemic corticosteroids, epinephrine | Emergency treatment |
Peak Flow Monitoring:
- Green zone (80-100% of personal best): Good control
- Yellow zone (50-79%): Caution, use rescue inhaler
- Red zone (< 50%): Medical alert, seek emergency care
Pneumonia
Pneumonia is an infection of the lung parenchyma causing consolidation.
Types:
| Type | Causative Agent | Characteristics |
|---|---|---|
| Community-Acquired (CAP) | Streptococcus pneumoniae, viruses | Develops outside healthcare setting |
| Hospital-Acquired (HAP) | MRSA, Pseudomonas | Develops 48+ hours after admission |
| Aspiration | Mixed flora, anaerobes | From aspiration of oral/gastric contents |
Pneumonia Signs and Symptoms:
- Fever, chills
- Productive cough (may be rust-colored sputum)
- Dyspnea, tachypnea
- Chest pain (pleuritic)
- Crackles, bronchial breath sounds
- Elevated WBC
Nursing Interventions:
- Administer antibiotics as ordered
- Encourage coughing and deep breathing
- Incentive spirometry
- Adequate hydration (thins secretions)
- Position for maximum lung expansion
- Monitor oxygen saturation
Pulmonary Embolism (PE)
Pulmonary embolism occurs when a clot (usually from DVT) travels to the lungs.
Risk Factors (Virchow's Triad):
- Venous stasis: Immobility, surgery, long travel
- Vessel damage: Trauma, surgery
- Hypercoagulability: Cancer, pregnancy, clotting disorders
PE Signs and Symptoms:
- Sudden dyspnea
- Sharp, pleuritic chest pain
- Tachycardia, tachypnea
- Hypoxia
- Anxiety, sense of impending doom
- May have signs of DVT (unilateral leg swelling)
PE Management:
- Oxygen therapy
- Anticoagulation (heparin → warfarin or DOACs)
- Thrombolytics in massive PE
- IVC filter if anticoagulation contraindicated
- Prevention: Early ambulation, SCDs, anticoagulation prophylaxis
Tuberculosis (TB)
TB is a bacterial infection (Mycobacterium tuberculosis) primarily affecting the lungs.
TB Transmission:
- Airborne droplet nuclei
- Requires prolonged close contact
- Not spread by touching surfaces
Latent vs. Active TB:
| Feature | Latent TB | Active TB |
|---|---|---|
| Symptoms | None | Night sweats, weight loss, persistent cough, hemoptysis |
| Infectious | No | Yes |
| Chest X-ray | May be normal | Often abnormal |
| Treatment | INH for 6-9 months | Multi-drug regimen for 6-12 months |
TB Precautions:
- Airborne isolation (negative pressure room)
- N95 respirator for healthcare workers
- Patient wears surgical mask during transport
- Continue until three negative sputum AFB smears
Chest Tubes
Indications: Pneumothorax, hemothorax, pleural effusion, post-thoracic surgery
Chest Tube Care:
- Keep drainage system below chest level
- Maintain water seal (2 cm water)
- Monitor for tidaling (normal fluctuation with respiration)
- Continuous bubbling in water seal = air leak
- Assess drainage color, amount (> 100 mL/hr is concerning)
- Never clamp except briefly for troubleshooting or system change
- Keep petroleum gauze at bedside (for accidental removal)
A patient with COPD is receiving oxygen therapy. What is the target oxygen saturation range for this patient?
A patient with a chest tube has continuous bubbling in the water seal chamber. What does this indicate?
What type of isolation precautions are required for a patient with active pulmonary tuberculosis?