Distinguishing the two conditions in a stem
Asthma is a reversible inflammatory airway disease with intermittent episodes triggered by allergens, exercise, cold air or infection. Between attacks the client may be entirely well. Chronic obstructive pulmonary disease is progressive and largely irreversible, dominated by chronic bronchitis and emphysema, and driven overwhelmingly by tobacco exposure. Recognising which one you are dealing with changes what counts as a normal baseline.
In COPD the exam expects you to accept findings that would alarm you in another client. A barrel chest, prolonged expiratory phase, baseline saturation in the low 90s or high 80s, and a chronic productive cough are all expected. What is not expected is a change from that baseline: new confusion, worsening dyspnoea at rest, a change in sputum colour or volume, or a saturation that has fallen below the client's usual range.
In asthma the graded severity of an attack is the whole question. Mild attacks show wheezing on expiration and mild dyspnoea. Moderate attacks add accessory muscle use and difficulty speaking in full sentences. Severe attacks bring inability to speak more than a few words, a rising respiratory rate, and then the ominous combination of a quiet chest, drowsiness, bradycardia and a falling saturation, which indicates impending respiratory failure.
Peak expiratory flow readings often anchor these items. Green zone is 80 to 100 percent of personal best and means continue the usual plan. Yellow is 50 to 79 percent and means use the rescue inhaler and follow the action plan. Red is under 50 percent and means take the rescue medication and seek emergency care.
- •Asthma: reversible, episodic, trigger-driven
- •COPD: progressive, chronic, smoking-related
- •Peak flow green 80–100%, yellow 50–79%, red under 50%
- •Silent chest, drowsiness or bradycardia in asthma equals emergency
Inhalers, order of administration and technique
The single most tested procedural fact in this area is inhaler sequencing. When a client uses both a short-acting beta agonist such as albuterol and an inhaled corticosteroid such as fluticasone, the bronchodilator goes first. It opens the airways so the steroid can be deposited deeper into the lungs. Wait at least one minute, or as ordered up to five, between the two, and rinse the mouth after the steroid to prevent oral thrush and hoarseness.
Technique details also appear. With a metered-dose inhaler the client shakes the canister, exhales fully, seals the lips around the mouthpiece or spacer, presses and inhales slowly and deeply, then holds the breath for about ten seconds. Spacers improve delivery and reduce oropharyngeal deposition and are recommended for children and older adults. Dry powder inhalers are different: do not shake, do not exhale into the device, and inhale quickly and forcefully.
Drug roles must be separated cleanly. Short-acting beta agonists are rescue medication for acute symptoms. Long-acting beta agonists such as salmeterol and anticholinergics such as tiotropium are maintenance drugs and must never be used to treat an acute attack. Inhaled corticosteroids are controllers taken daily even when the client feels well. Montelukast is a preventive oral agent and will not relieve an acute episode.
Expect adverse effect items. Albuterol causes tachycardia, tremor and nervousness, which are expected rather than alarming at usual doses. Theophylline has a narrow therapeutic range of 10 to 20 mcg/mL, and nausea, restlessness and tachydysrhythmias signal toxicity. Anticholinergics cause dry mouth and urinary retention and are cautioned in glaucoma.
| Drug group | Example | Role | Key nursing point |
|---|---|---|---|
| Short-acting beta agonist | Albuterol | Rescue | Expect tremor and tachycardia; use first in the sequence |
| Long-acting beta agonist | Salmeterol | Maintenance | Never for an acute attack; used with a steroid |
| Inhaled corticosteroid | Fluticasone | Controller | Rinse mouth to prevent candidiasis |
| Anticholinergic | Ipratropium, tiotropium | Maintenance | Dry mouth; caution in glaucoma and BPH |
| Leukotriene modifier | Montelukast | Preventive | Oral, daily; monitor for mood changes |
| Methylxanthine | Theophylline | Adjunct | Therapeutic range 10–20 mcg/mL |
Oxygen, positioning and self-management teaching
Oxygen therapy in COPD is a classic exam trap. The target saturation is 88 to 92 percent, delivered by low-flow nasal cannula, typically 1 to 3 litres per minute unless otherwise ordered. Applying high-flow oxygen to a client with chronic carbon dioxide retention can suppress respiratory drive and worsen hypercapnia. That said, never withhold oxygen from a hypoxic client in distress — treat the hypoxia and monitor closely.
Positioning and breathing techniques are almost always correct answers. High Fowler's or the tripod position, leaning forward with arms braced on a table, improves diaphragmatic excursion. Pursed-lip breathing prolongs exhalation, prevents small airway collapse and reduces air trapping. Diaphragmatic breathing strengthens the primary muscle of respiration. Teach the client to exhale for roughly twice as long as inhalation.
Long-term management teaching includes smoking cessation as the only intervention that slows COPD progression, annual influenza vaccination and pneumococcal vaccination, energy conservation with rest between activities, small frequent high-calorie meals because eating is physically tiring, and adequate hydration to thin secretions unless fluids are restricted.
Reinforce this with our oxygenation and respiratory question guide, the respiratory medications article and the adult health question bank, which contain NGN-style items on exacerbation triage and inhaler teaching.
- •Target 88–92 percent saturation in known COPD
- •Tripod position and pursed-lip breathing relieve air trapping
- •Smoking cessation is the only disease-modifying step
- •Small, frequent, calorie-dense meals reduce fatigue
- •Report a change in sputum colour, volume or new fever