Respiratory Disorders: Assessment, Airway Management, and Oxygen Therapy

Respiratory Assessment: Why It Matters

Respiratory problems are among the most common and most urgent issues you will encounter as an LPN. A thorough, systematic respiratory assessment allows you to detect early changes, report findings accurately to the supervising RN or provider, and act within your scope of practice to keep patients safe. Always assess the airway first — no other intervention matters if the patient cannot breathe.

Performing a Focused Respiratory Assessment

Work in a consistent order: inspection, palpation, percussion, auscultation.

Inspection — Observe the patient's general appearance. Note skin and lip color (cyanosis is a late, serious sign), level of consciousness, and use of accessory muscles (neck, shoulders, intercostals). Count the respiratory rate for a full 60 seconds. Normal adult rate is 12–20 breaths per minute. Note depth, rhythm, and any audible sounds such as stridor or wheezing. Check for a barrel chest (seen in long-standing COPD) and asymmetrical chest rise.

Palpation — Place your hands symmetrically on the chest wall. Feel for equal expansion bilaterally. Assess for crepitus (a crackling sensation under the skin that may indicate air leakage), tenderness, and fremitus (vibrations felt when the patient speaks).

Percussion — Tap the chest to detect resonance patterns. Resonance is normal over air-filled lung tissue. Dullness suggests fluid or consolidation (pneumonia, pleural effusion). Hyperresonance may indicate air trapping (emphysema, pneumothorax).

Auscultation — Use the diaphragm of your stethoscope directly on the skin, not over clothing. Ask the patient to breathe slowly and deeply through the mouth. Compare side to side from apex to base.

• Vesicular — soft, low-pitched; heard over most peripheral lung fields; normal.
• Bronchovesicular — medium pitch; heard near the mainstem bronchi; normal in those locations.
• Bronchial (tubular) — loud, high-pitched; normal only over the trachea; if heard over peripheral lung it suggests consolidation.
• Wheezes — high-pitched, musical; caused by narrowed airways; common in asthma and COPD.
• Crackles (rales) — fine or coarse popping sounds; caused by fluid in airways or alveoli reopening; associated with pneumonia, heart failure, pulmonary edema.
• Stridor — harsh, high-pitched sound heard on inspiration; indicates upper airway obstruction — treat as an emergency.
• Absent or diminished sounds — may indicate pneumothorax, severe obstruction, mucus plugging, or pleural effusion.

Always correlate breath sound findings with vital signs, oxygen saturation, and the patient's reported symptoms.

Supplemental Oxygen Delivery Devices

Oxygen is a medication. Verify the order, select the appropriate device, and document flow rate and patient response.

| Device | Approximate FiO₂ | Typical Flow Rate | Key Indication |

|---|---|---|---|

| Nasal cannula | 24–44% | 1–6 L/min | Mild hypoxia; patient comfort |

| Simple face mask | 35–50% | 6–10 L/min | Moderate hypoxia |

| Venturi mask | Precise, adjustable | Per color-coded adapter | COPD; precise FiO₂ needed |

| Non-rebreather mask (NRB) | Up to ~90% | 10–15 L/min | Severe hypoxia; emergency |

| Aerosol nebulizer | Varies | Per order | Medication delivery; humidification |

Safety point — COPD and oxygen: Patients with chronic CO₂ retention (hypercapnic COPD) may rely on a low oxygen level as their drive to breathe. Administering high-flow oxygen to these patients can suppress respirations. Use a Venturi mask or low-flow nasal cannula as ordered; titrate carefully and monitor closely.

Ensure the reservoir bag on an NRB remains inflated; if it collapses completely, the patient may inhale CO₂. Keep the bag at least one-third to one-half full at all times.

Priority Nursing Considerations for Common Respiratory Disorders

Pneumonia — Assess for fever, productive cough, pleuritic chest pain, and crackles or bronchial sounds over the affected lobe. Nursing priorities include positioning the patient upright (high Fowler's), encouraging deep breathing and coughing, ensuring adequate hydration, administering prescribed antibiotics and antipyretics on time, and monitoring oxygen saturation. Report increasing work of breathing or a declining SpO₂ promptly.

COPD Exacerbation — The patient often presents with increased dyspnea, change in sputum color or volume, and audible wheezes or diminished sounds. Keep oxygen saturation in the range ordered by the provider (often a conservative target). Administer prescribed bronchodilators via nebulizer or inhaler. Position upright and encourage pursed-lip breathing. Avoid high-flow oxygen without specific orders.

Asthma — Hallmarks are wheezing, chest tightness, and a dry cough. Severity ranges from mild to life-threatening status asthmaticus. Priority actions include administering prescribed short-acting bronchodilators, positioning upright, monitoring peak flow if ordered, and notifying the provider if the patient does not respond to initial treatment. Silent chest (no wheezing because airflow is so limited) is an emergency sign.

Pulmonary Embolism (PE) — Sudden onset of dyspnea, pleuritic chest pain, tachycardia, and anxiety in a patient with risk factors (immobility, recent surgery, deep vein thrombosis) should raise suspicion for PE. Nursing priorities: keep the patient calm, apply supplemental oxygen, position upright, obtain vital signs and SpO₂, notify the RN or provider immediately, and prepare for diagnostic testing. Do not leave the patient alone.

General Safety Reminders

• Confirm that oxygen equipment is free of oil or grease and that no open flames are nearby — oxygen accelerates combustion.
• Check nares and ears under nasal cannula tubing regularly to prevent pressure injury.
• Document baseline assessment, device applied, flow rate, and patient response every time.
• Know when to escalate: respiratory rate above 30, SpO₂ below 90% on supplemental oxygen, use of accessory muscles, altered mental status, or stridor require immediate RN/provider notification.