COPD Nursing Care
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Direct answer
The man who cannot blow out a match at arm's length has obstructed airways, and the number that proves it is a post-bronchodilator FEV1/FVC ratio below 0.70 — the fixed diagnostic threshold of chronic obstructive pulmonary disease. Nursing care splits into the long game and the acute one. Between exacerbations: inhaled bronchodilators with checked technique, pulmonary rehabilitation, vaccination, nutrition, energy conservation, smoking cessation — and, in Indian practice, recognition that decades of biomass chulha smoke give non-smoking women the same disease cigarettes give men. During an exacerbation: controlled oxygen titrated to a saturation of 88-92 per cent (high-flow oxygen in a carbon-dioxide retainer causes narcosis and coma), nebulised bronchodilators, corticosteroids, antibiotics when sputum turns purulent, and non-invasive ventilation for a falling pH.
What you must remember
- Diagnosis: post-bronchodilator FEV1/FVC below 0.70 confirms persistent airflow obstruction; symptoms and exacerbation history, not spirometry alone, drive treatment decisions.
- Oxygen rule: target SpO2 88-92 per cent in exacerbation with carbon-dioxide retention — the classic nursing pearl, because hypoxic-drive loss under high-flow oxygen leads to rising PaCO2, drowsiness and arrest.
- mMRC dyspnoea scale: grade 0 breathless on strenuous exercise only, 1 on hurrying uphill, 2 walking slower than peers, 3 stopping after 100 metres, 4 too breathless to leave the house.
- Exacerbation trio: short-acting bronchodilators (salbutamol with ipratropium), systemic corticosteroids, and antibiotics when sputum is purulent — plus controlled oxygen and non-invasive ventilation for pH below 7.35.
- Breathing techniques: pursed-lip exhalation keeps airways open against collapse and relieves trapping; forward-leaning sitting lets accessory muscles work; huffing clears sputum without exhausting coughing.
- BODE index: Body mass index, Obstruction (FEV1), Dyspnoea (mMRC) and Exercise capacity (six-minute walk) — a composite predicting survival better than FEV1 alone.
- Prevention package: annual influenza and pneumococcal vaccination, smoking cessation with the Ask-Advise-Assess-Assist-Arrange structure, and smokeless-chulha counselling where biomass drives the disease.
- Discharge safety net: a written action plan — what worsened symptoms mean, when to start the rescue pack, whom to call — with inhaler technique re-checked and follow-up fixed.
An exacerbation admitted at 2 a.m.
A 68-year-old with known COPD arrives blue-lipped and tripod-shaped, speaking in fragments, saturation 74 per cent on room air, respirations 30. The nurse's first act is oxygen — 24-28 per cent via a Venturi mask, not a flood: the target is 88-92 per cent, and within thirty minutes the saturation reads 90 with the patient visibly less distressed. Nebulised salbutamol and ipratropium run back-to-back, an intravenous corticosteroid starts, and because his sputum has turned yellow-green over two days, antibiotics follow. The first arterial gas shows pH 7.29 with PaCO2 of 68 — the threshold at which non-invasive ventilation begins — and a BiPAP mask is fitted with the coach-and-stay discipline the first hour demands.
By morning he trades full sentences for breaths, and the teaching half begins. Inhaler technique is watched and corrected and the spacer demonstrated. His wife learns the forward-lean position and pursed-lip exhalation for bad hours at home, and the action plan is written in her hand: rescue pack contents, the symptoms that mean starting it, the morning to come in. Vaccination status is updated and pulmonary rehabilitation booked before discharge. Nothing in that list is glamorous; all of it, done every time, keeps the next 2 a.m. from happening.
Where candidates slip
The oxygen error is the trap set in every paper: "a COPD patient arrives with saturation 74 — your oxygen order?" — the failing answer is a non-rebreather at 15 litres, the passing answer is controlled Venturi oxygen titrated to 88-92 per cent with gases and consciousness monitored. The second is the diagnostic number quoted without "post-bronchodilator", which is what separates COPD's fixed obstruction from asthma's reversibility. Education questions lose marks on vagueness — "teach breathing exercises" scores nothing against naming pursed-lip exhalation with its mechanism of preventing airway collapse. The Indian differentiator is aetiology: any complete answer on risk factors names biomass fuel smoke alongside smoking, because the female non-smoker with chulha-exposure COPD is a district-hospital everyday patient that Western summaries under-describe.
Frequently asked questions
What spirometry value diagnoses COPD?
A post-bronchodilator FEV1/FVC ratio below 0.70, indicating persistent airflow obstruction — the fixed threshold distinguishing COPD from asthma's reversibility.
Why is oxygen controlled to 88-92 per cent in COPD exacerbation?
Chronic carbon-dioxide retention makes hypoxic drive important; high-concentration oxygen removes it, the PaCO2 climbs and the patient progresses from drowsy to comatose.
What are the mMRC grades?
A 0-4 breathlessness scale, from grade 0 (only strenuous exercise) to grade 4 (too breathless to leave the house or dress), used to grade symptoms and guide therapy.
What three drug classes form the core of a COPD exacerbation?
Short-acting bronchodilators (salbutamol plus ipratropium), systemic corticosteroids, and antibiotics when sputum is purulent — with controlled oxygen and non-invasive ventilation for acidosis.
What is pursed-lip breathing and why is it taught?
Slow exhalation through pursed lips, which raises airway pressure during breathing out, prevents small-airway collapse, reduces trapping and eases the work of breathing.