NLE Respiratory Nursing — Chronic Obstructive & Restrictive Pulmonary DisordersCheat Sheet
One-page cheat sheet for NLE Respiratory Nursing — Chronic Obstructive & Restrictive Pulmonary Disorders. Every formula, definition, and key fact you need for this chapter, condensed to a single printable page. Designed for the final review session before the NLE 2026.
Exam context
For the Philippine Nurse Licensure Examination (PNLE), Professional Regulation Commission (PRC) — Board of Nursing tests Respiratory Nursing under a "Core" label, with Chronic Obstructive & Restrictive Pulmonary Disorders in the 3rd slot across 4 chapters. NLE candidates must clear the 75% weighted average with no sub-test below 60% cut on the 2026 paper, which draws about 50 Respiratory Nursing questions. Date to watch: Bi-annual.
Chronic Obstructive & Restrictive Pulmonary Disorders - Cheat Sheet
Your last-minute revision companion for respiratory nursing's most testable chapter. Master COPD pathophysiology, oxygen titration protocols, asthma vs COPD distinctions, and emergency pneumothorax management — all condensed for exam-day confidence.
Sections
Formulas
Formula
FEV1/FVC ratio < 70% (NOT fully reversible with bronchodilator) = COPD diagnosis
Meaning
FEV1 = Forced Expiratory Volume in 1 second; FVC = Forced Vital Capacity; ratio <70% with lack of reversibility confirms obstructive disease
Watch Out
Students confuse reversibility: COPD = irreversible obstruction; Asthma = reversible obstruction. A reversible ratio <70% is asthma, NOT COPD.
When To Use
Spirometry interpretation to differentiate COPD from asthma (asthma IS reversible)
Formula
Target SpO2 for COPD patient = 88–92% (NOT >94%)
Meaning
SpO2 = peripheral oxygen saturation; safe range for CO2 retainers to avoid suppressing hypoxic drive
Watch Out
Giving high-flow oxygen aiming for SpO2 >94% can trigger CO2 narcosis and respiratory depression in COPD patients. TITRATE to 88–92% and use a Venturi mask for precision.
When To Use
Every oxygen prescription in a COPD patient; the #1 safety rule in this chapter
Section Title
COPD: Chronic Obstructive Pulmonary Disease
Important Facts
- COPD is progressive, largely IRREVERSIBLE airflow limitation caused by smoking (and in Philippines: biomass/cooking-fuel smoke, occupational exposure).
- Chronic bronchitis = 'blue bloater': cyanotic, oedematous, copious sputum, hypoxaemia, hypercapnia, cor pulmonale.
- Emphysema = 'pink puffer': barrel chest, pursed-lip breathing, minimal cough, dyspnoea on exertion, accessory muscle use, thin/wasted appearance.
- ABG pattern in COPD: CHRONIC RESPIRATORY ACIDOSIS with METABOLIC COMPENSATION → high PaCO2, elevated HCO3, near-normal pH, low PaO2.
- Chest X-ray findings: hyperinflation, flattened diaphragms, increased AP diameter.
- SAFETY: Use LOW-FLOW oxygen devices or Venturi mask; NEVER titrate by 'sats' alone in COPD — monitor blood gas and mental status.
- Short-acting bronchodilators (SABA, SAMA) for relief; long-acting (LABA, LAMA) for maintenance; side effects of beta-agonists: tachycardia, tremor.
- Inhaled corticosteroids (ICS): rinse mouth AFTER EVERY USE to prevent oral candidiasis.
- Acute exacerbations triggered by infection, air pollution, non-compliance; recognize by increased dyspnoea, sputum change, fever.
- Complications: respiratory failure, cor pulmonale, secondary polycythaemia (from chronic hypoxaemia), pneumothorax from ruptured bullae, pneumonia.
Key Definitions
Term
Chronic Bronchitis
Example
A 65-year-old smoker with 5 years of daily productive cough, cyanosis, and peripheral edema ('blue bloater').
Definition
Productive cough ≥3 months in 2 consecutive years from airway inflammation, mucus-gland hypertrophy, and excessive mucus production.
Term
Emphysema
Example
A 58-year-old with barrel chest, pursed-lip breathing, dyspnea on exertion, thin appearance ('pink puffer').
Definition
Permanent destruction of alveolar walls, loss of elastic recoil, and formation of bullae causing air trapping and loss of gas-exchange surface.
Term
Alpha-1 Antitrypsin Deficiency
Example
A 40-year-old non-smoker presenting with emphysema and family history of early lung disease.
Definition
Genetic deficiency of protective enzyme → early-onset emphysema in non-smokers or young smokers.
Term
Cor Pulmonale
Example
COPD patient with peripheral edema, jugular venous distension, and hepatomegaly.
Definition
Right-sided heart failure secondary to chronic lung disease from chronic hypoxaemia and pulmonary hypertension.
Diagrams To Know
- Airway narrowing progression in chronic bronchitis: inflammation → mucus-gland hypertrophy → excessive mucus → air trapping → hypoxaemia.
- Emphysematous lung: alveolar destruction → loss of elastic recoil → bullae formation → air trapping → reduced gas-exchange surface.
- Pathophysiology flowchart: Smoking/Biomass exposure → Chronic airway damage → COPD (bronchitis + emphysema) → Cor pulmonale.
Formulas
Formula
Venturi mask FiO2 = precise, controlled oxygen concentration (24%, 28%, 31%, 35%, 40%, 50%)
Meaning
FiO2 = Fraction of Inspired Oxygen; Venturi uses air-entrainment to deliver exact concentrations regardless of patient flow
Watch Out
Nasal cannula is UNCONTROLLED (FiO2 varies with flow; 1–6 L/min ≠ precise percentages). Use Venturi for COPD.
When To Use
COPD patients requiring oxygen, especially CO2 retainers needing precise SpO2 88–92% titration
Common Values
Value
88–92%
Symbol
SpO2
Quantity
COPD oxygen saturation target
Value
80–100 mmHg
Symbol
PaO2
Quantity
Normal arterial oxygen partial pressure
Value
35–45 mmHg
Symbol
PaCO2
Quantity
Normal arterial CO2 partial pressure
Section Title
COPD Nursing Management & Oxygen Therapy
Important Facts
- PRIORITY INTERVENTION: Controlled oxygen therapy, SpO2 target 88–92%, Venturi mask preferred for CO2 retainers.
- NEVER withhold oxygen from a hypoxic COPD patient; always titrate and monitor.
- High-Fowler's positioning or tripod position (leaning forward on overbed table) reduces work of breathing.
- Teach pursed-lip and diaphragmatic breathing to all COPD patients.
- Maintain hydration to thin secretions; avoid large meals (crowd diaphragm, worsen dyspnoea) — prefer small, frequent, high-calorie meals.
- Airway clearance: controlled coughing, chest physiotherapy, humidification.
- Infection prevention: pneumococcal vaccine (once, revaccinate every 5 years if age ≥65 or CD4 <200), annual influenza vaccine.
- Exacerbation warning signs: increased dyspnoea, sputum colour change (from white to yellow/green), fever, increased sputum volume.
- Energy conservation: rest between activities, avoid exertion during meals, use assistive devices.
- Monitor ABG, not just SpO2, to assess true gas exchange; elevated PaCO2 or falling pH signals worsening.
Key Definitions
Term
Hypoxic Drive
Example
COPD patient breathing is triggered by low O2, not by high CO2; giving high-flow O2 removes this trigger → respiratory depression.
Definition
In CO2 retainers, hypoxaemia (low PaO2) becomes the primary stimulus to breathe because chronic high CO2 has blunted the normal CO2 drive.
Term
CO2 Narcosis (Hypercapnic Encephalopathy)
Example
COPD patient given high-flow O2, becomes confused, develops headache → PaCO2 is dangerously high.
Definition
Mental status changes, confusion, headache, and lethargy from excessive CO2 retention triggered by inappropriate high-flow oxygen in a CO2-retaining patient.
Term
Pursed-Lip Breathing
Example
Patient taught to exhale to a count of 4 with pursed lips to keep alveoli open during exhalation.
Definition
Technique: inhale through nose, exhale slowly through pursed lips → maintains positive airway pressure, prevents premature airway collapse, reduces air trapping.
Term
Diaphragmatic (Abdominal) Breathing
Example
Patient lies semi-recumbent, places hand on abdomen, breathes in to expand belly, out to contract.
Definition
Breathing using the diaphragm and abdominal muscles rather than accessory muscles → more efficient, less energy expenditure.
Diagrams To Know
- Oxygen delivery systems spectrum: Nasal cannula (1–6 L/min, uncontrolled FiO2) → Simple face mask → Venturi mask (24–50%, controlled FiO2) → Non-rebreather.
- COPD exacerbation response flowchart: Assess SpO2 & respiratory distress → Titrate O2 to 88–92% → Monitor ABG → Bronchodilators → Corticosteroids if indicated.
Formulas
Formula
Theophylline therapeutic range = 10–20 mcg/mL (narrow margin)
Meaning
Serum concentration below 10 mcg/mL is subtherapeutic; above 20 mcg/mL is toxic
Watch Out
Theophylline toxicity causes tachycardia, nausea, vomiting, seizures, arrhythmias. Never exceed 20 mcg/mL. Half-life varies by smoking status and drugs (CYP1A2 interactions).
When To Use
If theophylline is prescribed (now rare); monitor serum levels closely
Common Values
Value
10–20 mcg/mL
Symbol
Therapeutic range
Quantity
Theophylline therapeutic level
Section Title
COPD Pharmacology
Important Facts
- RELIEVER (rescue): SABA (salbutamol) — fast-acting for acute bronchospasm.
- CONTROLLER (maintenance): ICS, LABA + ICS, LAMA, leukotriene modifiers (montelukast).
- Beta-agonist side effects: tachycardia, tremor, anxiety, hyperglycaemia; use spacer to reduce systemic absorption.
- Anticholinergic (ipratropium) side effects: dry mouth, constipation, urinary retention; use in combination with SABA in acute exacerbations.
- ICS side effect: oral candidiasis if mouth not rinsed; other: hoarseness, dysphonia.
- Systemic corticosteroid side effects: hyperglycaemia, immunosuppression, osteoporosis, GI upset; taper slowly after prolonged use to avoid adrenal insufficiency.
- Antibiotics for exacerbations with purulent sputum (sign of bacterial infection).
- Theophylline rarely used; narrow therapeutic range, multiple drug interactions (CYP1A2), unpredictable absorption.
- Mucolytics (e.g., bromhexine, ambroxol) thin secretions; N-acetylcysteine is an antioxidant.
- Patient education: Use spacer for all inhalers to improve drug deposition; rinse mouth after ICS; check inhaler technique every visit.
Key Definitions
Term
Short-Acting Beta-2 Agonist (SABA)
Example
Patient uses salbutamol inhaler PRN for acute wheezing; side effects: tachycardia, tremor, jitteriness.
Definition
e.g., salbutamol/albuterol — rapid bronchodilation for acute relief; onset 5–15 min, duration 4–6 hours.
Term
Long-Acting Beta-2 Agonist (LABA)
Example
Seretide (salmeterol + fluticasone) taken twice daily for maintenance.
Definition
e.g., salmeterol, formoterol — maintenance therapy, onset 10–20 min, duration 12+ hours; NEVER use alone (risk of death), always combine with ICS.
Term
Long-Acting Muscarinic Antagonist (LAMA)
Example
Tiotropium inhaled once daily for baseline bronchodilation.
Definition
e.g., tiotropium — anticholinergic maintenance bronchodilator, once-daily, duration 24 hours.
Term
Inhaled Corticosteroid (ICS)
Example
Patient rinses mouth after every ICS use to prevent oral candidiasis.
Definition
e.g., fluticasone, budesonide — reduce airway inflammation; used daily for maintenance or for frequent exacerbators.
Term
Acute Corticosteroid Course
Example
Patient given prednisone 50 mg daily for 5 days during exacerbation; taper after, monitor blood glucose.
Definition
Short-course systemic corticosteroid (e.g., prednisone 40–60 mg daily × 5–7 days) for acute exacerbation; never stop abruptly after prolonged use.
Diagrams To Know
- Drug action timeline: SABA (5–15 min onset) vs LABA (10–20 min onset) vs LAMA (onset ≈ LABA, but 24-hour duration).
- Corticosteroid taper: Do NOT stop abruptly; taper over days to weeks after prolonged use to restore HPA axis function.
Common Values
Value
>80% of personal best
Symbol
PEFR
Quantity
PEFR green zone (well-controlled)
Value
50–80% of personal best
Symbol
PEFR
Quantity
PEFR yellow zone (caution)
Value
<50% of personal best
Symbol
PEFR
Quantity
PEFR red zone (emergency)
Section Title
Chronic Asthma
Important Facts
- Asthma is REVERSIBLE airway obstruction (contrast with COPD, which is irreversible).
- Triggers: allergens, exercise, cold air, smoke, infections, aspirin/NSAIDs, emotional stress.
- Manifestations: expiratory wheezing (prolonged expiration), cough, chest tightness, dyspnoea.
- CRITICAL: 'Silent chest' with severe distress = impending respiratory failure, NOT improvement.
- Diagnosis: FEV1/FVC ratio <70% that IS REVERSIBLE with bronchodilator (opposite of COPD).
- RELIEVER: SABA (salbutamol) for acute bronchospasm; onset within minutes.
- CONTROLLER: Inhaled corticosteroids (daily); LABA only combined with ICS, never monotherapy.
- Acute severe attack (status asthmaticus): Oxygen, nebulised salbutamol + ipratropium, IV/oral corticosteroids, IV magnesium sulfate, consider ICU admission.
- PEFR action plan: green zone (>80%) = continue current therapy; yellow zone (50–80%) = increase SABA, contact doctor; red zone (<50%) = emergency.
- Patient education: Correct inhaler technique with spacer, trigger avoidance, medication adherence, PEFR self-monitoring.
Key Definitions
Term
Asthma
Example
Child with wheezing, chest tightness, dyspnoea triggered by running (exercise-induced), relieved by salbutamol inhaler.
Definition
Chronic inflammatory airway disorder with REVERSIBLE bronchospasm, mucosal oedema, mucus plugging, triggered by allergens, exercise, cold air, smoke, or infection.
Term
Status Asthmaticus
Example
Patient in severe distress, unable to speak full sentences, inadequate response to nebulised salbutamol and ipratropium, requires ICU admission.
Definition
Severe, prolonged asthma attack unresponsive to standard bronchodilators; a MEDICAL EMERGENCY with risk of respiratory failure.
Term
Silent Chest
Example
Patient looks severely distressed, barely speaks, but NO wheeze heard → do NOT be reassured; this is more dangerous than audible wheeze.
Definition
Absence of audible wheeze in a severely obstructed patient due to minimal airflow; OMINOUS SIGN of critical obstruction and impending respiratory failure.
Term
Peak Expiratory Flow Rate (PEFR)
Example
Patient's PEFR in green zone (>80% personal best) = well-controlled; yellow zone (50–80%) = caution; red zone (<50%) = emergency.
Definition
Maximum airflow during forced exhalation; used for patient self-monitoring and asthma control assessment.
Diagrams To Know
- Asthma control spectrum: Intermittent (occasional symptoms) → Mild persistent (1–3 days/week) → Moderate persistent (3–6 days/week) → Severe persistent (daily/continuous).
- Asthma medication ladder: Step 1 (intermittent SABA) → Step 2 (low-dose ICS) → Step 3 (low-dose ICS + LABA or medium-dose ICS) → Step 4 (high-dose ICS + LABA) → Step 5 (specialist therapy).
Section Title
Bronchiectasis
Important Facts
- Hallmark: LARGE AMOUNTS of thick, purulent, foul-smelling sputum (often layered, 'three-layer sputum').
- Often follows severe/recurrent respiratory infections (including TB — HIGHLY RELEVANT in Philippines).
- Manifestations: chronic productive cough, recurrent infections, haemoptysis, crackles on auscultation, clubbing of fingers.
- Diagnosis: High-resolution CT (HRCT) is gold standard; shows bronchus-to-artery ratio >1 (bronchus larger than accompanying artery).
- PRIORITY NURSING INTERVENTION: Airway clearance via postural drainage + chest physiotherapy + adequate hydration.
- Teach patient a DAILY routine of airway clearance (morning, evening, as tolerated).
- Bronchodilators and mucolytics support secretion clearance; nebulization with saline or medications.
- Antibiotics prescribed for exacerbations (purulent sputum = bacterial infection).
- Vaccination: pneumococcal and annual influenza to reduce infection risk.
- Complications: respiratory failure, haemoptysis, cor pulmonale if extensive disease.
Key Definitions
Term
Bronchiectasis
Example
Post-TB bronchiectasis in a Filipino patient with history of pulmonary TB, now presenting with chronic purulent cough.
Definition
Permanent, abnormal dilation of the bronchi from chronic infection/inflammation that destroys the elastic and muscular layers of airway walls.
Term
Postural Drainage
Example
Right lower-lobe drainage: Trendelenburg position at 45° with patient on left side; left lower-lobe drainage: reverse position.
Definition
Positioning patient to use gravity to drain secretions from specific lung lobes into the airways, usually followed by chest physiotherapy.
Term
Chest Physiotherapy (Chest PT)
Example
Therapist percusses patient's back in pattern over lower lobes during postural drainage to mobilize secretions.
Definition
Manual percussion and vibration of chest wall over affected lung areas to dislodge secretions and promote airway clearance.
Diagrams To Know
- Postural drainage positions: Right upper lobe (upright, lean back); Right middle lobe (Trendelenburg 45°, right side); Right lower lobe (Trendelenburg 45°, left side); Left upper lobe (upright, lean forward-left); Left lower lobe (Trendelenburg 45°, right side); Lingula (Trendelenburg 45°, left side elevated).
- Bronchiectasis pathogenesis: Chronic infection → Airway wall damage → Elastic/muscular layer destruction → Permanent dilation → Impaired mucociliary clearance → Recurrent infection cycle.
Formulas
Formula
Spirometry pattern: Reduced FVC with NORMAL or INCREASED FEV1/FVC ratio (opposite of obstructive disease)
Meaning
FVC = Forced Vital Capacity (reduced overall lung volume); FEV1/FVC = usually >70% because expiration is normally fast relative to reduced total volume
Watch Out
Students reverse this: restrictive = low FVC + normal ratio; obstructive = low ratio. Remember: restrictive = 'volume problem', obstructive = 'flow problem'.
When To Use
Interpreting spirometry to differentiate restrictive from obstructive disease
Common Values
Value
2–3 years
Symbol
Prognosis
Quantity
IPF median survival without treatment
Section Title
Restrictive Pulmonary Disorders
Important Facts
- Restrictive disease = reduced lung volumes (low FVC), normal or increased FEV1/FVC ratio (opposite of COPD).
- Causes: pulmonary fibrosis (idiopathic or occupational), sarcoidosis, chest-wall deformity (kyphoscoliosis), neuromuscular disease (myasthenia gravis, ALS), severe obesity.
- Manifestations: progressive exertional dyspnoea, DRY non-productive cough, fine (Velcro) crackles at lung bases, clubbing, reduced lung volumes.
- Idiopathic pulmonary fibrosis (IPF): poor prognosis (median survival 2–3 years if untreated); antifibrotic agents (pirfenidone, nintedanib) slow progression.
- Management is largely SUPPORTIVE: treat underlying cause, supplemental oxygen for hypoxaemia, pulmonary rehabilitation, advance-care planning.
- Diagnosis: clinical presentation + spirometry + HRCT showing reticular opacities and traction bronchiectasis (IPF) or specific patterns (occupational disease).
- OCCUPATIONAL DISEASES are HIGHLY PREVALENT in Philippines (mining, construction, agriculture) — screen for exposure history.
- Monitoring: Serial spirometry to track decline, 6-minute walk test (6MWT) for functional assessment, ABG/pulse oximetry during exertion.
- Prognosis: POOR for most restrictive diseases; IPF is progressive; occupational diseases plateau if exposure stops, but damage is permanent.
- End-of-life planning: discuss goals of care, do-not-intubate orders, palliative care early in disease course.
Key Definitions
Term
Pulmonary Fibrosis
Example
Idiopathic pulmonary fibrosis (IPF) patient with progressive dyspnoea, fine crackles, reduced lung volumes, 'Velcro' crackles on auscultation.
Definition
Progressive replacement of normal lung tissue with fibrous (collagen-containing) tissue → loss of elasticity, reduced lung volumes, restrictive pattern.
Term
Velcro Crackles (Fine Crackles)
Example
Auscultation of IPF patient reveals bilateral fine crackles at bases.
Definition
Fine, high-pitched crackles heard at lung bases, characteristic of pulmonary fibrosis; sound like Velcro being pulled apart.
Term
Sarcoidosis
Example
Patient with sarcoidosis presenting with dyspnoea, restrictive spirometry, elevated serum ACE level, hilar lymphadenopathy on chest X-ray.
Definition
Multisystem granulomatous inflammatory disease often affecting lungs → restrictive pattern, may progress to pulmonary fibrosis.
Term
Occupational Lung Disease
Example
Silicosis in quarry worker; asbestosis in former construction worker → restrictive pattern with pleural plaques on imaging.
Definition
Restrictive disease from chronic inhalation of occupational particles (silica, asbestos, coal dust, organic dusts) → progressive fibrosis.
Term
Kyphoscoliosis
Example
Patient with severe scoliosis from untreated idiopathic adolescent scoliosis presents with restrictive spirometry and dyspnoea.
Definition
Severe spinal curvature (kyphosis + scoliosis) causing chest-wall deformity → mechanical restriction of lung expansion.
Diagrams To Know
- Restrictive disease spectrum: Occupational exposures → Chronic inflammation → Progressive fibrosis → Restrictive spirometry pattern → Reduced exercise tolerance → Respiratory failure.
- Pulmonary fibrosis progression: Normal lung → Inflammation → Early fibrosis (few symptoms, normal imaging) → Established fibrosis (dyspnoea, crackles, HRCT changes) → Advanced fibrosis (severe hypoxaemia, cor pulmonale).
Common Values
Value
≤1.5–2 L per hour
Symbol
Max drain rate
Quantity
Safe drainage rate to prevent re-expansion pulmonary oedema
Section Title
Pneumothorax
Important Facts
- Tension pneumothorax is a MEDICAL EMERGENCY requiring IMMEDIATE intervention.
- Red flags for tension pneumothorax: TRACHEAL DEVIATION TOWARD UNAFFECTED SIDE (away from pneumothorax), distended neck veins, severe hypotension, cyanosis, profound distress.
- TREATMENT of tension pneumothorax: Needle decompression (large-bore needle, 2nd intercostal space, midclavicular line) followed by chest-tube insertion.
- Open chest wound PRIORITY: apply occlusive dressing taped on 3 sides to create flutter valve (allow pressure relief), NOT 4 sides (can convert to tension).
- Larger or symptomatic pneumothorax: managed with chest tube to water-seal drainage system to evacuate air and re-expand lung.
- CONTINUOUS BUBBLING in water-seal chamber = ongoing air leak; monitor and report.
- Give HIGH-FLOW OXYGEN (in non-CO2-retaining patient) — speeds pleural air reabsorption (nitrogen is replaced by oxygen).
- Positioning: High-Fowler's to ease breathing; maintain patient safety during emergency procedures.
- Complications: recurrence (10–50% recur), tension pneumothorax, cardiac arrest, respiratory failure, re-expansion pulmonary oedema (from too-rapid lung re-expansion).
- Re-expansion pulmonary oedema risk: if >1.5–2 L drained rapidly, limit drainage rate to prevent fluid leak into alveoli (dyspnoea, pink frothy sputum).
Key Definitions
Term
Pneumothorax
Example
Spontaneous pneumothorax in a 22-year-old tall, thin male from rupture of an apical bleb; presents with sudden chest pain and dyspnoea.
Definition
Presence of air in the pleural space, causing partial or complete lung collapse by disrupting negative intrapleural pressure.
Term
Spontaneous Pneumothorax
Example
Young patient with sudden-onset pleuritic chest pain, dyspnoea, decreased breath sounds on one side.
Definition
Rupture of a bleb or bulla in the absence of trauma; most common in tall, thin young men; also occurs in emphysema from ruptured bullae.
Term
Traumatic Pneumothorax
Example
Motor vehicle accident victim with penetrating chest wound → sucking sound heard, air bubbling from wound.
Definition
Pneumothorax resulting from penetrating or blunt chest trauma, including open ('sucking') chest wound.
Term
Tension Pneumothorax
Example
Chest trauma patient with tracheal deviation away from pneumothorax side, distended neck veins, severe hypotension, cyanosis.
Definition
ONE-WAY VALVE mechanism: air enters pleura but cannot escape → progressive pressure buildup → lung collapse, mediastinal shift, compression of heart/great vessels → LIFE THREAT.
Term
Open (Sucking) Chest Wound
Example
Stabbing victim with wound through anterior chest wall; air enters with each breath, patient gasps 'I can't breathe'.
Definition
Penetrating wound through chest wall that allows atmospheric air to enter pleural space; may convert to tension pneumothorax if sealed improperly.
Term
Flutter Valve
Example
Occlusive dressing taped on top, left, right sides but left loose at bottom — allows air to escape during exhalation, prevents entry during inhalation.
Definition
Partial seal of a wound allowing trapped air to escape but preventing new air from entering; created by taping occlusive dressing on 3 sides.
Diagrams To Know
- Pneumothorax types: Spontaneous (bleb rupture in healthy lung, bullae rupture in emphysema) vs Traumatic (penetrating injury, blunt trauma, open wound).
- Tension pneumothorax mechanism: One-way valve → Air in but not out → Progressive pressure → Lung collapse + Mediastinal shift → Heart/vessel compression → Shock.
- Emergency response sequence: Recognize tension (tracheal deviation, hypotension, distended JVD) → Needle decompression (2nd ICS, mid-clavicular) → Chest tube insertion → Water-seal drainage.
- Open chest wound dressing: 3-sided tape (flutter valve) vs 4-sided tape (tension risk) — MUST know this distinction.
Formulas
Formula
ABG interpretation in COPD: HIGH PaCO2 (>45 mmHg) + HIGH HCO3 (>26 mEq/L) + NEAR-NORMAL pH (7.35–7.45) = Chronic respiratory acidosis with metabolic compensation
Meaning
PaCO2 = arterial CO2; HCO3 = bicarbonate (kidney compensation); pH near-normal due to slow compensation
Watch Out
Acute respiratory acidosis (new-onset) has HIGH PaCO2 but NORMAL HCO3 and LOW pH (<7.35). Do NOT confuse chronic (compensated) with acute (decompensated).
When To Use
Assessing COPD patient's gas exchange and severity; distinguishing chronic from acute respiratory acidosis
Formula
FEV1/FVC ratio interpretation: <70% = obstructive pattern; >70% or normal = non-obstructive. In obstructive disease, check reversibility: >12% improvement post-bronchodilator = ASTHMA (reversible); <12% = COPD (irreversible)
Meaning
FEV1 = volume exhaled in 1st second; FVC = total forceful expiration; reversibility tests bronchodilator response
Watch Out
Some COPD patients show partial reversibility (10–12%); if clinical context favors COPD (smoking history, irreversible obstruction on previous tests), diagnose COPD not asthma.
When To Use
Spirometry interpretation to differentiate asthma from COPD
Common Values
Value
>70%
Symbol
Ratio
Quantity
Normal FEV1/FVC ratio
Value
35–45 mmHg
Symbol
PaCO2
Quantity
Normal PaCO2
Value
7.35–7.45
Symbol
pH
Quantity
Normal pH
Value
22–26 mEq/L
Symbol
HCO3
Quantity
Normal HCO3
Value
>1
Symbol
HRCT finding
Quantity
Bronchus-to-artery ratio in bronchiectasis
Section Title
Diagnostic Findings & Interpretation
Important Facts
- Chest X-ray in COPD: hyperinflation, flattened diaphragms, increased AP diameter, decreased pulmonary markings (emphysema), possibly cor pulmonale changes.
- Chest X-ray in asthma (acute): may be normal or show hyperinflation; status asthmaticus may show infiltrates if complicated by pneumonia.
- Chest X-ray in bronchiectasis: bronchial wall thickening, bronchus-to-vessel ratio >1 (but HRCT is more sensitive).
- Chest X-ray in pulmonary fibrosis: reticular opacities, ground-glass appearance, traction bronchiectasis, honeycomb pattern (late).
- Chest X-ray in pneumothorax: radiolucency (dark area) representing lung collapse; visceral pleural line visible; confirm with inspiration and expiration films.
- HRCT is gold standard for bronchiectasis (bronchus-to-artery ratio), IPF, and occupational lung diseases.
- ABG is CRITICAL in COPD exacerbation: assess severity and guide oxygen titration; elevated PaCO2 or falling pH indicates worsening.
- Spirometry is the functional test; imaging (X-ray, HRCT) is structural confirmation.
- ECC findings in cor pulmonale: right atrial enlargement, right ventricular hypertrophy, peaked P waves.
Key Definitions
Term
Hyperresonance on Percussion
Example
Emphysema patient: percussion over lungs produces hyperresonance bilaterally; pneumothorax patient: hyperresonance on affected side only.
Definition
Hollow, drum-like sound on chest percussion indicating air trapping (emphysema) or pneumothorax.
Term
Barrel Chest
Example
Emphysema patient with rounded chest profile and increased AP diameter on chest X-ray.
Definition
Increased anterior-posterior (AP) diameter of chest from chronic air trapping; associated with emphysema.
Term
Flattened Diaphragm
Example
COPD chest X-ray: diaphragms are flattened (horizontal) instead of normally curved.
Definition
Loss of normal dome shape of diaphragm on chest X-ray from chronic air trapping and hyperinflation.
Term
Clubbing
Example
Bronchiectasis patient: fingernails are enlarged, rounded, angle between nail and nail bed >180°.
Definition
Enlargement of fingertips/toenails from chronic hypoxia; seen in bronchiectasis, IPF, and chronic suppurative lung disease.
Diagrams To Know
- ABG interpretation algorithm: Check pH first → Acidemia (pH <7.35) or Alkalemia (pH >7.45) → Identify primary process (respiratory vs metabolic) → Check for appropriate compensation.
- Spirometry pattern differentiation: Obstructive (low FEV1/FVC, low FVC variably) vs Restrictive (low FVC, normal/high FEV1/FVC) vs Normal (both normal).
Section Title
Patient Education & Prevention (All Chronic Lung Disorders)
Important Facts
- SMOKING CESSATION is the SINGLE MOST EFFECTIVE intervention to slow COPD progression.
- In Philippines: address BIOMASS/COOKING-SMOKE exposure (wood, charcoal fires indoors) — educate on improved ventilation, clean fuels.
- Occupational exposure assessment: ask all patients about job exposures (construction, mining, agriculture, welding, grain handling).
- Teach pursed-lip and diaphragmatic breathing to ALL chronic lung patients; practice together during clinic visit.
- Inhaler technique education: demonstrate with actual patient inhaler + spacer, have patient return-demonstrate, reinforce at every visit.
- ICS education: rinse mouth AFTER EVERY USE; brush teeth to prevent oral candidiasis; use spacer to reduce systemic absorption.
- Vaccination: pneumococcal (once, revaccinate every 5 years if age ≥65), annual influenza vaccine (BEFORE season).
- Exacerbation recognition: increased dyspnoea, sputum color/volume change, fever → seek care promptly; do NOT wait.
- Nutrition: small, frequent, high-calorie meals; avoid large meals that worsen dyspnoea; ensure adequate protein for muscle maintenance.
- Pulmonary rehabilitation programs: formal exercise training, education, psychosocial support — improve quality of life, reduce hospitalizations.
Key Definitions
Term
Smoking Cessation
Example
Nurse counsels COPD patient on quit-smoking strategies: NRT, medications (varenicline, bupropion), behavioral support, quitlines.
Definition
Permanent discontinuation of tobacco smoking; most effective intervention to slow COPD progression and reduce exacerbation risk.
Term
Biomass Smoke Exposure (Indoor Air Pollution)
Example
Rural Filipino household: woman cooks over open fire inside home without ventilation → chronic biomass exposure → COPD.
Definition
Chronic inhalation of smoke from wood, charcoal, crop residues, or dung used for cooking/heating in low-resource settings; major COPD risk in Philippines.
Term
Occupational Lung Exposure
Example
Philippine quarry worker inhales silica dust for 10 years → silicosis with restrictive pattern.
Definition
Chronic workplace inhalation of dusts/fumes (silica, asbestos, coal, grain dust, metal fumes) → restrictive or mixed disease; must be documented for compensation.
Diagrams To Know
- Smoking cessation counseling elements: Assess readiness → Ask about triggers → Advise personalized quit strategy → Assess barriers → Arrange follow-up → Offer NRT/pharmacotherapy.
- Inhaler technique: Shake device → Exhale fully → Place in mouth or attach spacer → Actuate while inhaling → Hold breath 10 sec → Wait 1 min before next puff if multiple.
Section Title
NANDA Nursing Diagnoses & NCM Levels (Philippine Context)
Important Facts
- NCM Level 1 (NCM I) — Community Health Nursing: Smoking cessation counseling, health promotion, disease prevention (vaccination, workplace safety), early detection.
- NCM Level 2 (NCM II) — Medical-Surgical Nursing: Assessment, acute/chronic disease management, medication education, respiratory support, emergency care.
- NCM Level 3 (NCM III) — Critical Care: Mechanical ventilation, hemodynamic monitoring, intensive support for respiratory failure, pneumothorax emergency procedures.
- NCM Level 4 (NCM IV) — Community Health Nursing: Case management, discharge planning, community follow-up, coordination with barangay health centers.
- Key NANDA diagnoses in chronic lung disease: Ineffective Airway Clearance, Impaired Gas Exchange, Activity Intolerance, Anxiety, Ineffective Coping.
- Maslow prioritization: Immediate life threat (tension pneumothorax, status asthmaticus) → Physiologic (airway, breathing, gas exchange) → Safety (infection prevention, medication adherence) → Psychological (anxiety, adaptation).
- RA 9173 (Nursing Practice Law in Philippines): Nurses can perform independent interventions (airway clearance, patient education, positioning, breathing exercises); collaborative with physicians (oxygen titration, medication adjustment).
- Philippine healthcare context: Limited access to pulmonary rehab, HRCT, advanced imaging in rural areas; emphasize home-based strategies (breathing exercises, infection prevention, energy conservation).
- Cultural considerations: Philippines has high smoking prevalence; strong family influence on health decisions; use family-centered education.
- Follow-up care: Refer to tertiary center (Philippine General Hospital, UP-PGH, etc.) for spirometry, HRCT, pulmonary specialist if available; document findings for continuity.
Key Definitions
Term
Ineffective Airway Clearance
Example
Bronchiectasis patient unable to clear copious sputum despite coughing; interventions: postural drainage, chest PT, airway suctioning.
Definition
NANDA diagnosis indicating inability to clear secretions/obstructions from airway; priority in bronchiectasis, COPD exacerbation, acute asthma.
Term
Impaired Gas Exchange
Example
COPD patient with PaO2 55 mmHg, PaCO2 65 mmHg, SpO2 86%; intervention: oxygen titration to 88–92%, positioning, bronchodilators.
Definition
NANDA diagnosis indicating imbalance in oxygen/CO2 transfer; seen in all chronic lung disorders, especially COPD, restrictive disease, pneumothorax.
Term
Activity Intolerance
Example
COPD patient becomes severely dyspneic walking to bathroom; intervention: energy conservation, rest periods, pulmonary rehab.
Definition
NANDA diagnosis indicating insufficient energy/oxygen for activities of daily living; priority in advanced COPD, IPF.
Term
Anxiety related to Dyspnoea
Example
Asthma patient panics during attack, worsening bronchospasm; intervention: calm reassurance, slow breathing, anxiety medication PRN.
Definition
NANDA diagnosis of fear/panic from breathlessness; creates cycle (anxiety → increased breathing effort → more dyspnoea).
Diagrams To Know
- NANDA-to-Intervention mapping: Ineffective Airway Clearance → Postural drainage, chest PT, hydration; Impaired Gas Exchange → Oxygen titration, positioning, bronchodilators; Activity Intolerance → Energy conservation, pacing, rehab.
- Nursing care priority hierarchy: ABCs (Airway, Breathing, Circulation) → Gas exchange → Infection prevention → Comfort → Psychosocial support.
Must Remember
- COPD OXYGEN TARGET = 88–92% SpO2 (NOT >94%). High-flow O2 suppresses hypoxic drive → CO2 narcosis. Use Venturi mask for precision. NEVER fully withhold O2 from hypoxic patient; titrate and monitor.
- COPD is IRREVERSIBLE obstructive disease (FEV1/FVC <70%, <12% bronchodilator reversibility). ASTHMA is REVERSIBLE (FEV1/FVC <70%, >12% bronchodilator response or normal spirometry between attacks).
- Chronic bronchitis = 'BLUE BLOATER' (cyanotic, edematous, productive cough, hypoxic, hypercapnic, cor pulmonale early). Emphysema = 'PINK PUFFER' (barrel chest, pursed-lip breathing, thin, dyspnea on exertion, minimal cough).
- ABG in COPD = CHRONIC RESPIRATORY ACIDOSIS WITH METABOLIC COMPENSATION: high PaCO2 (>45), high HCO3 (>26), near-normal pH (7.35–7.45), low PaO2. Rising CO2 or falling pH = acute decompensation.
- ASTHMA red flag: 'SILENT CHEST' (no audible wheeze with severe distress) = severe obstruction and impending respiratory failure. Do NOT be reassured by absence of wheeze.
- TENSION PNEUMOTHORAX is MEDICAL EMERGENCY: tracheal deviation TOWARD unaffected side (AWAY from pneumothorax), distended neck veins, hypotension, cyanosis → NEEDLE DECOMPRESSION immediately (2nd ICS, midclavicular line) then chest tube.
- OPEN CHEST WOUND = apply OCCLUSIVE DRESSING on 3 SIDES (flutter valve allows air escape, prevents entry). NEVER tape all 4 sides (converts to tension pneumothorax).
- BRONCHIECTASIS priority = AIRWAY CLEARANCE: postural drainage (use gravity) + chest physiotherapy (percussion/vibration) + hydration + mucolytics. Hallmark: large volumes of thick, purulent, foul-smelling sputum.
- RESTRICTIVE DISEASE = reduced FVC with NORMAL/INCREASED FEV1/FVC ratio (opposite of obstructive). Pulmonary fibrosis: fine 'Velcro' crackles, clubbing, progressive dyspnea, poor prognosis (median survival 2–3 years untreated).
- SMOKING CESSATION is THE SINGLE MOST EFFECTIVE intervention to slow COPD. In Philippines: address BIOMASS/COOKING-SMOKE exposure (indoors without ventilation). Occupational exposures (silica, asbestos, construction, mining) must be documented for compensation and prevention.
Last Minute Tips
- OXYGEN TITRATION IN COPD is the #1 safety concept tested on NLE. Remember: CO2 retainers cannot tolerate high O2 → use Venturi mask for 88–92% target. If student forgets this, they will fail COPD questions. Drill it: 88–92%, Venturi, monitor blood gas and mental status.
- REVERSIBILITY is the key distinction between asthma and COPD. Asthma spirometry shows >12% FEV1 improvement post-bronchodilator; COPD shows <12% improvement. Practice spirometry interpretation with this rule until automatic.
- Tension pneumothorax red flags are tested every NLE cycle. Memorize the clinical triad: (1) TRACHEAL DEVIATION AWAY from collapsed lung, (2) DISTENDED NECK VEINS, (3) HYPOTENSION + severe distress. If you see this constellation, think NEEDLE DECOMPRESSION FIRST, chest tube second.
- Open chest wound requires 3-sided dressing taping, NOT 4 sides. This is a high-yield detail that appears in scenario questions. If question asks 'what dressing?' and options include 'tape all 4 sides,' that's a TRAP — select 3 sides.
- ICS (inhaled corticosteroids) — rinse mouth after EVERY USE. This phrase appears in medication education questions and is a common NLE scenario. If you miss this, patient develops oral candidiasis → complication you failed to prevent.
Comparison Tables
Rows
Values
- Irreversible airflow obstruction
- Reversible bronchospasm
Property
Reversibility
Values
- <70%, <12% improvement with bronchodilator
- <70%, >12% improvement with bronchodilator (or normal spirometry between attacks)
Property
Spirometry FEV1/FVC
Values
- Smoking (and biomass, occupational exposure in Philippines)
- Allergic reaction, hyperresponsiveness, triggers (exercise, cold, infection, allergens)
Property
Primary cause
Values
- Gradual, progressive over years (age 40+)
- Often in childhood/young adults; acute episodic attacks
Property
Onset of symptoms
Values
- Chronic productive cough; copious sputum in bronchitis
- Usually none between attacks; little or no sputum during attack
Property
Sputum
Values
- Barrel chest, pursed-lip breathing, accessory muscle use, cyanosis, cor pulmonale in late disease
- Wheezing (may be absent in severe attack — 'silent chest'), chest tightness, normal exam between attacks
Property
Physical signs
Values
- Hyperinflation, flattened diaphragms, increased AP diameter, decreased markings
- Usually normal; may show hyperinflation during acute attack
Property
Chest X-ray
Values
- Chronic respiratory acidosis with metabolic compensation (high CO2, high HCO3, near-normal pH)
- During acute attack: acute respiratory acidosis or alkalosis; between attacks: normal
Property
ABG pattern
Values
- SABA (salbutamol) for acute bronchospasm; limited effect due to irreversibility
- SABA (salbutamol) — very effective, rapid relief
Property
Reliever medication
Values
- LABA, LAMA, ICS if frequent exacerbations
- ICS (daily), LABA + ICS, leukotriene modifiers
Property
Controller medication
Values
- 88–92% (risk of CO2 narcosis if higher)
- >94% (no CO2 retention risk in most cases)
Property
Oxygen target SpO2
Values
- Progressive decline in lung function; smokers who quit show slower decline
- Variable; many have periods of remission; prognosis good if controlled; risk of severe attacks (status asthmaticus)
Property
Prognosis
Columns
- Feature
- COPD
- Asthma
Table Title
COPD vs Asthma — Key Distinctions for NLE
Rows
Values
- Airflow limitation (difficulty getting air OUT)
- Reduced lung expansion (difficulty getting air IN)
Property
Primary defect
Values
- Normal or mildly reduced
- Significantly reduced
Property
FVC
Values
- <70% (low ratio)
- >70% or normal (normal/high ratio relative to reduced FVC)
Property
FEV1/FVC ratio
Values
- 'Flow problem' — hard to push air out fast
- 'Volume problem' — less air to push out
Property
Spirometry memory aid
Values
- Airway narrowing (inflammation, mucus, bronchoconstriction), air trapping
- Alveolar destruction/fibrosis, chest-wall deformity, neuromuscular weakness, obesity
Property
Causes
Values
- Productive (sputum present)
- Dry non-productive (no sputum, or minimal)
Property
Cough characteristics
Values
- Late crackles at bases (if present); coarse crackles suggest bronchiectasis
- Fine 'Velcro' crackles at bases (pulmonary fibrosis)
Property
Crackles
Values
- Yes (emphysema)
- No
Property
Barrel chest
Values
- With exertion, may have nocturnal dyspnea; progressive
- Progressive exertional dyspnea, even minimal activity
Property
Dyspnea onset
Values
- Late finding in bronchiectasis; not common in pure COPD
- Common in IPF, bronchiectasis, sarcoidosis
Property
Clubbing
Values
- COPD: progressive but may stabilize if smoking stops; asthma: variable, often good control possible
- Poor in IPF (median 2–3 years); others variable depending on cause
Property
Prognosis
Columns
- Feature
- Obstructive (COPD, Asthma)
- Restrictive (Fibrosis, Sarcoidosis, Chest Wall Deformity)
Table Title
Obstructive vs Restrictive Pulmonary Disease
Rows
Values
- Airway inflammation, mucus-gland hypertrophy, excessive mucus, airway narrowing
- Alveolar wall destruction, loss of elastic recoil, bullae formation, air trapping
Property
Pathology
Values
- 'Blue bloater' — cyanotic, oedematous, appears ill
- 'Pink puffer' — thin, wasted, barrel chest, pursed-lip breathing, appears to be 'working hard'
Property
Presentation
Values
- Chronic productive cough with copious sputum
- Minimal cough, little sputum
Property
Cough
Values
- Later in disease course
- Earlier and more prominent (dyspnea on exertion)
Property
Dyspnea onset
Values
- Normal or only slightly hyperinflated
- Barrel chest (increased AP diameter)
Property
Chest wall appearance
Values
- Relatively preserved until late disease
- Significantly decreased/absent throughout
Property
Breath sounds
Values
- Early hypoxaemia and hypercapnia → cor pulmonale early
- Better preserved initially; hypoxaemia and hypercapnia develop late
Property
Gas exchange status
Values
- Severe, chronic CO2 retention (hypercapnia) — hypoxic drive dependent
- Milder or late CO2 retention
Property
CO2 retention
Values
- Develops early
- Develops late
Property
Cor pulmonale
Values
- May suppress hypoxic drive; titrate carefully to 88–92%
- Generally tolerates higher SpO2 (though still exercise caution; 88–92% safest)
Property
Response to oxygen
Columns
- Feature
- Chronic Bronchitis
- Emphysema
Table Title
Chronic Bronchitis ('Blue Bloater') vs Emphysema ('Pink Puffer')
Rows
Values
- Rupture of bleb/bulla; no external trauma
- Penetrating or blunt chest trauma
- One-way valve mechanism; air in but not out
Property
Cause
Values
- Tall, thin young men; emphysema patients
- Trauma victims; can occur in anyone
- Any pneumothorax can deteriorate to tension
Property
Patient population
Values
- Sudden sharp pleuritic pain, dyspnea, decreased breath sounds
- As spontaneous + signs of trauma
- As above PLUS distended JVD, tracheal deviation AWAY from pneumothorax, severe hypotension, cyanosis, shock
Property
Presentation
Values
- Decreased/absent breath sounds on affected side
- Open wound: bubbling, sucking sound; closed: as spontaneous
- Trachea shifted TOWARD unaffected side (away from pneumothorax)
Property
Classic sign
Values
- Hyperresonance on affected side
- Hyperresonance (closed) or open wound
- Hyperresonance + signs of shock
Property
Percussion finding
Values
- Radiolucency (dark area) with visceral pleural line visible
- As spontaneous; may also show rib fractures, hemothorax
- Tracheal deviation, mediastinal shift, lung collapse
Property
Chest X-ray
Values
- Reassure, position high-Fowler's, oxygen, observe for tension development, prepare for chest tube if symptomatic/large
- OPEN WOUND: apply occlusive dressing on 3 SIDES (flutter valve), NOT 4 sides; high-flow O2; prepare for needle decompression if tension develops
- IMMEDIATE needle decompression (2nd ICS, midclavicular line) BEFORE chest tube; high-flow O2; rapid transport to OR for surgical evaluation
Property
INITIAL nursing priority
Values
- Small + asymptomatic: observation; large or symptomatic: chest tube to water-seal drainage
- Chest tube; surgical repair if significant air leak or hemothorax
- Needle decompression + chest tube; may require surgical intervention
Property
Definitive treatment
Values
- Do NOT seal wound if present (convert to tension risk)
- Do NOT tape occlusive dressing on all 4 sides (converts to tension)
- Do NOT delay intervention — this is life-threatening
Property
Critical do-NOT
Columns
- Feature
- Spontaneous
- Traumatic
- Tension (EMERGENCY)
Table Title
Pneumothorax Types & Emergency Response
Rows
Values
- Near-normal (7.35–7.45) due to renal compensation
- Low (<7.35) in mild-to-moderate attack; very low if severe, or high (>7.45) if hyperventilation in early attack
- Depends on severity; if mild: normal; if severe: acidemia
Property
pH
Values
- HIGH (>45 mmHg), often 50–70 mmHg or higher
- Normal to low (30–45 mmHg) in mild; elevated if severe/status asthmaticus
- Normal unless severe respiratory compromise
Property
PaCO2
Values
- Low (55–75 mmHg typically); chronic hypoxemia
- Low if moderate-severe attack; normal if mild attack with good oxygenation
- May be low if large pneumothorax or significant shunting
Property
PaO2
Values
- HIGH (>26 mEq/L), often 28–32 mEq/L (renal retention of bicarbonate = metabolic compensation)
- Normal unless prolonged attack; in status asthmaticus may show mixed picture
- Normal unless prolonged hypoxemia triggers metabolic changes
Property
HCO3
Values
- Respiratory acidosis + metabolic (renal) compensation = CHRONIC RESPIRATORY ACIDOSIS
- Respiratory acidosis (high CO2, low pH) if severe; respiratory alkalosis (low CO2, high pH) if hyperventilation early
- Depends on severity; usually normal unless decompensating
Property
Acid-base diagnosis
Values
- Expected pattern in COPD; baseline for patient; rising PaCO2 or falling pH signals acute decompensation requiring intervention
- Severity correlates with PaCO2: rising PaCO2 is ominous sign of fatigue/status asthmaticus; indicates need for aggressive treatment/ICU
- Monitor for deterioration; may need mechanical support if PaCO2 rises significantly
Property
Clinical significance
Columns
- ABG Pattern
- COPD (Chronic)
- Acute Asthma Attack
- Pneumothorax (if respiratory distress)
Table Title
ABG Interpretation in Chronic Lung Disease
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