Respiratory · Topic 13 of 19
COPD
The biggest mistake in COPD management isn't forgetting a medication — it's giving too much oxygen.
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COPD
Floppy airways trap air and CO₂. Oxygen to 88–92%, pursed lips, stop smoking.
A small airway and its cluster of alveoli in COPD. Breathing out, the floppy airway wall collapses and pinches shut before the air has left, so the alveoli stay big with air trapped inside: labeled OBSTRUCTIVE, air can’t get out (versus restrictive, can’t get in). Carbon dioxide builds up: the PaCO2 climbs from 42 to 58, above the normal 35 to 45.
- Breathing out, the floppy airway collapsesNurse seesprolonged expiration, wheezeNurse doessit upright: high Fowler's or tripod
- Air is trapped in the sacsNurse seesdyspnea on exertion; later a barrel chestNurse doesteach pursed-lip breathing
- CO₂ builds upNurse seesPaCO₂ above 45 (normal 35–45)Nurse doescheck the pH: compensated or failing?
For a patient at risk of CO₂ retention · most adults: 94–98% · start low: 1–2 L/min by nasal cannula
In through the nose, out slowly through pursed lips — it holds the airways open so trapped air and CO₂ get out
Slows the disease, eases symptoms and cuts flare-ups — at any stage
Oxygen: aim for 88–92%
CO₂ retentionAn oxygen flowmeter and a pulse oximeter panel for a COPD patient. The flow is turned up from 2 to 6 L/min and the SpO2 climbs to 98%, past the 88 to 92% target. The PaCO2 climbs from 50 to 70 and the level of consciousness changes from alert to drowsy: CO2 narcosis. The flow is turned back down and the SpO2 settles back inside 88 to 92%.
- Oxygen turned up: SpO₂ over 92%Nurse seesSpO₂ above the 88–92% targetNurse doesstart low: 1–2 L/min nasal cannula
- CO₂ builds up: PaCO₂ climbsNurse seesthe SpO₂ looks fine; the PaCO₂ is risingNurse doesrecheck ABG and LOC 30–60 min after a change
- Drowsy: CO₂ narcosis — back to 88–92%Nurse seesnew drowsiness, confusion, hard to wakeNurse doesturn oxygen back to 88–92%; report now
Two subtypes
Know the differenceEmphysema destroys the alveoli; chronic bronchitis clogs the airways with mucus — both get the same COPD care
What causes it
Risk factorsSmoking is the main risk factor
What you'll see
SignsLabs & diagnostics
CheckSpirometry confirms COPD: FEV₁/FVC under 0.70 after a bronchodilator
Red flags
Act nowTreatment
Oxygen, position, flare drugsLow-flow oxygen to 88–92% · in a flare, a short-acting bronchodilator first
Flare: short-acting first. Daily: long-acting (LAMA such as tiotropium, LABA such as salmeterol). Every patient keeps a short-acting rescue inhaler.
Systemic, for about 5 days in a flare.
Inhaled steroids only for selected patients: frequent flares or high eosinophilsAdded in a flare when infection is the likely trigger.
Noninvasive ventilation is the first ventilation mode in a flare with respiratory failure — it lowers intubation, hospital days and deaths.
More detail
Pursed-lip breathing
Teach itPursed-lip breathing in COPD. The small airway starts collapsed with air and carbon dioxide trapped in overinflated alveoli. Breathing out slowly through pursed lips builds back-pressure that holds the floppy airway open, so the trapped air and carbon dioxide get out, the alveoli shrink back and the PaCO2 falls toward normal.
- Breathe out slowly through pursed lipsNurse doesteach: in through the nose, out through pursed lips
- Back-pressure holds the airway openNurse doespair it with tripod: leaning forward
- Trapped air and CO₂ get outNurse seesPaCO₂ falls toward normal
Nursing priorities
In orderTheir baseline, or failing?
Read the gasA high PaCO₂ alone is not the emergency — the pH tells you
| pH | Near-normal (7.35–7.45) |
|---|---|
| PaCO₂ | High, steady |
| HCO₃⁻ | High — kidneys holding bicarbonate |
| Level of consciousness | Their usual |
| Nurse does | Keep SpO₂ 88–92% — not an emergency |
Teach your patient
Before dischargeIn COPD, aim for 88–92% — more oxygen is not better. Drowsy on oxygen means the CO₂ is climbing.
Sources · OpenStax Medical-Surgical Nursing 11.5: Chronic Obstructive Pulmonary Disease · BTS Guideline for oxygen use in adults in healthcare and emergency settings — Web Appendix 5 · GOLD 2026 Report: Global Strategy for the Diagnosis, Management, and Prevention of COPD · Oxygen therapy in acute exacerbations of COPD (PMC review) · OpenStax Medical-Surgical Nursing 10.4: Acid-Base Imbalance · Physiotherapy for large airway collapse: an ABC approach (PMC) · OpenStax Medical-Surgical Nursing 11.2: Upper and Lower Respiratory Assessment · Emphysema (StatPearls, NCBI Bookshelf) · Chronic Bronchitis (StatPearls, NCBI Bookshelf) · Treatment of COPD: the simplicity is a resolved complexity (PMC review) · Films: the NurseSavvy learning-flow visuals. Follow your facility's protocol.
COPD
The biggest mistake in COPD management isn't forgetting a medication — it's giving too much oxygen. A well-meaning liter flow adjustment can suppress the only breathing drive left.
COPD management centers on maintaining the patient's hypoxic drive and preventing acute decompensation. In advanced COPD, chronic CO2 retention shifts the respiratory drive from CO2 sensitivity (normal) to hypoxemia sensitivity. Oxygen is titrated to a target SpO2 of 88–92%, typically at 1–2 L/min via nasal cannula. Higher flows can eliminate the hypoxic drive, causing respiratory depression and CO2 narcosis. Beyond oxygen, management is structured in layers: smoking cessation is the single intervention that slows disease progression. Bronchodilators (short-acting first, then long-acting) open airways. Pulmonary rehabilitation improves functional capacity and quality of life. Annual influenza and pneumococcal vaccines reduce exacerbation frequency. Pursed-lip breathing slows expiratory flow, prevents airway collapse, and reduces air trapping — teach it to every COPD patient. During exacerbations, monitor ABGs for rising PaCO2 and falling pH, which signal impending respiratory failure. Position the patient upright or in high Fowler's, encourage diaphragmatic breathing, and administer bronchodilators before corticosteroids.
Key Distinctions
Don't confuse the COPD oxygen target (88–92%) with the general target (≥95%) — applying the general target to a COPD patient can be lethal. Students mix up pursed-lip breathing (COPD — prevents airway collapse on exhalation) with incentive spirometry (postoperative — promotes deep inhalation). An ABG showing compensated respiratory acidosis (high CO2, near-normal pH, high bicarb) is baseline for COPD — don't panic-treat the CO2.
Clinical Pearl
Low and slow with O2: 1–2 L/min, target 88–92%. If SpO2 climbs above 92% on your watch, you're part of the problem, not the solution.
Knowledge Check
3 quick questions on the must-knows for this topic.
What is the target SpO2 range for a COPD patient?
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Go further
- Commonly confusedAsthma vs COPDReversible vs irreversible airway disease — similar wheeze, different management.
- GuideHow to Study for Med-Surg: Stop Memorizing, Start ConnectingMed-surg is the first course where memorizing stops working. Start every topic at the mechanism, climb from know-it to spot-it to act-on-it, and practice questions early at the right difficulty — with a real NGN bowtie to try in-page.
- QuizNursing study gamesSort look-alike conditions and drugs against the clock — the fast way to stop mixing them up.
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