Med-Surg · Respiratory
COPD & Asthma
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current drug references.
1. Overview and Pathophysiology
is a progressive, mostly preventable lung disease with persistent airflow limitation, usually from long-term smoking or biomass exposure. Two overlapping phenotypes:
- Chronic bronchitis: productive cough ≥ 3 months in 2 consecutive years; airway inflammation and mucus hypersecretion
- Emphysema: alveolar wall destruction → loss of elastic recoil and air trapping (“pink puffer” stereotype is oversimplified)
is a chronic inflammatory airway disease with reversible airflow obstruction, bronchial hyperresponsiveness, and episodic wheezing, cough, and dyspnea. Triggers include allergens, infection, cold air, exercise, and irritants.
| Feature | COPD | Asthma |
|---|---|---|
| Onset | Mid-life, progressive | Often childhood; can start any age |
| Reversibility | Mostly irreversible | Largely reversible with treatment |
| Smoking link | Strong | Variable |
| Inflammation | Neutrophilic / mixed | Often eosinophilic / allergic |
| Daily symptoms | Common, progressive | Episodic between attacks |
Exacerbations (worsening dyspnea, cough, sputum) drive hospitalizations and mortality. A “silent chest” during a severe asthma attack means airflow is so low you may not hear wheezes—an emergency.
2. Causes and Risk Factors
- COPD: tobacco smoke, occupational dusts/chemicals, indoor biomass fuel, alpha-1 antitrypsin deficiency, aging, recurrent infections
- Asthma: atopy/allergies, family history, viral infections, obesity, occupational exposures, GERD
- Exacerbation triggers: respiratory infection, air pollution, nonadherence to inhalers, allergens
3. Signs and Symptoms
COPD: progressive dyspnea, chronic cough, sputum, barrel chest, prolonged expiration, pursed-lip breathing, accessory muscle use, , fatigue, weight loss in advanced disease. SpO₂ often chronically lower.
Asthma: episodic wheezing, chest tightness, nocturnal cough, dyspnea after exposure/exercise. Severe attack: accessory muscles, inability to speak full sentences, peak flow drop, agitation, then fatigue/silent chest/cyanosis.
Early hypoxia: restlessness, anxiety, tachycardia. Late: cyanosis, confusion, bradycardia.
4. Diagnostics and Labs
Lab reference ranges vary by laboratory. Always use your facility’s ranges.
| Test | Typical reference / target | Nursing relevance |
|---|---|---|
| Spirometry FEV₁/FVC | < 0.70 post-bronchodilator supports COPD | Confirms obstruction; asthma shows reversibility |
| ABG: pH / PaCO₂ / HCO₃⁻ / PaO₂ | 7.35–7.45 / 35–45 / 22–26 / 80–100 | COPD often chronic with compensated respiratory acidosis |
| SpO₂ | Many COPD targets 88–92% | Avoid over-oxygenation in CO₂ retainers |
| Peak expiratory flow (asthma) | Personal best–based zones | Green/yellow/red action plan |
| WBC, sputum culture | Per lab | Infection-driven exacerbations |
| Alpha-1 antitrypsin | Lab-dependent | Young nonsmokers with emphysema |
| Chest X-ray / CT | — | Hyperinflation, bullae, rule out pneumonia/pneumothorax |
5. Priority Nursing Assessments
- RR, depth, effort, accessory muscles, positioning, ability to speak
- SpO₂ (know the client’s target), lung sounds, sputum color/amount
- Mental status (CO₂ narcosis, hypoxia)
- Peak flow / spirometry trends when ordered
- Medication technique and adherence; recent steroid or antibiotic use
- Hydration, nutrition, activity tolerance, anxiety
6. Priority Nursing Interventions
- Position upright / high Fowler’s; allow tripod if helpful
- Titrate O₂ to target (often 88–92% in COPD per order)—do not automatically crank to high flow
- Teach pursed-lip and diaphragmatic breathing; paced activity; energy conservation
- Hydration (if not contraindicated) to thin secretions; chest physiotherapy / flutter devices per order
- Inhaler sequence: bronchodilator before inhaled corticosteroid; wait between puffs as instructed; rinse mouth after steroids
- Vaccinations: influenza, pneumococcal, COVID-19 as indicated
- Smoking cessation support (most important COPD intervention)
- During severe exacerbation: nebulizers, systemic corticosteroids, antibiotics if bacterial, NIPPV for hypercapnic respiratory failure, prepare for intubation if tiring
7. Medications
| Class / examples | How it helps | Key nursing considerations |
|---|---|---|
| SABA (albuterol) | Rescue bronchodilation | Tachycardia, tremor, hypokalemia with heavy use; spacer improves delivery |
| SAMA/LAMA (ipratropium, tiotropium) | Anticholinergic bronchodilation | Dry mouth; tiotropium is maintenance, not rescue |
| LABA (salmeterol, formoterol) | Long-acting bronchodilation | Not for acute rescue alone; in asthma, combine with ICS |
| ICS (fluticasone, budesonide) | Reduce airway inflammation | Oral thrush/hoarseness—rinse and spit; pneumonia risk in COPD |
| Systemic corticosteroids | Exacerbation control | Hyperglycemia, infection risk, mood changes; taper if prolonged |
| Leukotriene modifiers (montelukast) | Asthma maintenance | Neuropsychiatric effects possible—teach to report |
| Methylxanthines (theophylline) | Rarely used bronchodilator | Narrow therapeutic index; toxicity = nausea, seizures, arrhythmias |
| PDE-4 inhibitor (roflumilast) | Severe COPD with chronic bronchitis | Weight loss, diarrhea, mood changes |
| Oxygen (long-term) | Survival benefit if severe resting hypoxemia | Fire safety; no smoking near O₂; titrate carefully |
8. Patient Education
- Correct inhaler / spacer technique with teach-back; know rescue vs controller
- Asthma action plan (green/yellow/red zones based on symptoms and peak flow)
- Avoid triggers; get vaccines; quit smoking—counsel without shaming
- Report increased sputum purulence, fever, or sudden dyspnea
- Home O₂ safety and target SpO₂ if prescribed
- Nutrition: small frequent meals for dyspneic clients; pulmonary rehab referral
9. Complications
- Acute respiratory failure /
- Cor pulmonale and right-sided HF
- Pneumothorax (bullae rupture)
- Pneumonia, pulmonary hypertension
- Status asthmaticus; silent chest; intubation
- Steroid-related hyperglycemia, osteoporosis, thrush
10. Memory Aids
- “88–92 for many COPD clients” (when ordered)—don’t chase 100%
- “Bronchodilator before steroid; rinse after steroid”
- “Silent chest = scream for help”
- COPD ≈ progressive & poorly reversible; asthma ≈ episodic & reversible
- Pursed lips = “smell the roses, blow out the candle”
11. NCLEX-Style Practice Questions
1. A client with COPD on 2 L/min nasal cannula has SpO₂ 89%, RR 20, and is resting comfortably. What should the nurse do?
A. Increase O₂ to 6 L/min
B. Apply a non-rebreather mask
C. Continue current therapy and monitor
D. Call the rapid response team
Answer: C. Many COPD clients have a target of 88–92%. This client is stable within target; excess O₂ can worsen CO₂ retention in some clients.
2. When teaching inhaler use, which sequence is correct?
A. Inhaled steroid, then albuterol
B. Albuterol first, then inhaled steroid; rinse mouth afterward
C. Both inhalers at the same time
D. Steroid only during attacks
Answer: B. Open airways with the bronchodilator first so the steroid reaches deeper; rinsing prevents thrush.
3. Which finding during an asthma attack is most concerning?
A. Loud expiratory wheezes
B. Peak flow in the yellow zone
C. Sudden absence of wheezes with increasing lethargy
D. Mild tachycardia after albuterol
Answer: C. A silent chest with fatigue suggests critically low airflow—prepare for emergency airway support.
4. A client with COPD asks why smoking cessation still matters. Best response?
A. “It won’t help once you have COPD.”
B. “Quitting slows further lung damage and reduces exacerbations, even after diagnosis.”
C. “You only need to quit if you use oxygen.”
D. “Switching to menthol cigarettes is enough.”
Answer: B. Smoking cessation is the most effective intervention to slow COPD progression at any stage.
5. Why must the nurse teach mouth rinsing after fluticasone?
A. Prevents systemic hypertension
B. Reduces oral candidiasis and hoarseness
C. Improves albuterol absorption
D. Prevents hypokalemia
Answer: B. Local steroid residue causes thrush and dysphonia; rinse and spit after each use.
References
Global Initiative for Asthma. (2025). Global strategy for asthma management and prevention. https://ginasthma.org/
Global Initiative for Chronic Obstructive Lung Disease. (2025). GLOBAL strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. https://goldcopd.org/
MedlinePlus. (n.d.). COPD. National Library of Medicine. Retrieved October 15, 2026, from https://medlineplus.gov/copd.html
MedlinePlus. (n.d.). Asthma. National Library of Medicine. Retrieved October 15, 2026, from https://medlineplus.gov/asthma.html
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page