Respiratory Map: COPD, Asthma, Pneumonia, PE, and Chest Tubes
COPD clients trap air and may live at an oxygen saturation in the high 80s or low 90s as their baseline, so they get low-flow oxygen (often 1 to 3 L/min) and close monitoring rather than withheld oxygen. Across the map the emergencies are a silent chest in asthma, sudden shortness of breath in a pulmonary embolism, and continuous bubbling in a chest tube's water seal chamber signaling an air leak.
COPD
What it is: long-term lung damage. Air gets trapped. The client cannot breathe out fully.
What you see: barrel-shaped chest, breathing out through pursed lips, sitting forward on the hands (tripod position), long expiration, chronic cough, low oxygen level that is normal for them.
Key point: a client with COPD may live at an oxygen saturation in the high 80s or low 90s. That is their baseline. Do not treat it as an emergency unless it is a change.
Oxygen: COPD clients are usually given low-flow oxygen, often 1 to 3 liters per minute, and their response is monitored closely.
Important balance: you do not withhold oxygen from someone who is dangerously hypoxic. You give what is needed and monitor. The old idea of avoiding oxygen entirely in COPD is not correct — but rates are kept low and the client is watched.
Teaching: pursed-lip breathing, energy conservation, small frequent high-calorie meals (eating is hard work when breathing is hard), infection prevention, and vaccines.
Asthma
What it is: airways narrow and swell, usually in response to a trigger.
What you see: wheezing, coughing, chest tightness, shortness of breath.
The warning sign that matters: a silent chest.
If wheezing stops and the chest becomes quiet, that is not improvement. It means almost no air is moving. This is an emergency.
What you do first: sit the client upright, give the rescue inhaler (a short-acting bronchodilator), give oxygen, and stay with them.
Inhaler teaching: bronchodilator before steroid. Rinse the mouth after a steroid inhaler.
Pneumonia
What it is: infection in the lungs.
What you see: fever, chills, productive cough, crackles, shortness of breath, chest pain with breathing. Older adults may present with confusion and no fever.
What you do: get cultures before the first antibiotic dose, give antibiotics on time, encourage deep breathing and coughing, use an incentive spirometer, push fluids to thin secretions, position upright.
Prevention is heavily tested: turn, cough, deep breathe, early walking after surgery, incentive spirometer, head of bed elevated for tube feeds and for clients at risk of aspiration.
Pulmonary embolism
What it is: a clot blocks blood flow in the lung. Usually travels from a leg clot.
What you see: sudden shortness of breath, sharp chest pain that is worse with breathing, fast heart rate, anxiety and a feeling of doom, low oxygen level, sometimes coughing blood.
The clue is SUDDEN onset in someone with risk factors.
Risk factors: recent surgery, immobility, long travel, fractures, cancer, pregnancy, birth control pills, clotting disorders.
What you do first: sit the client upright, give oxygen, notify the provider immediately, stay with them. Expect anticoagulation.
Prevention: early walking, compression devices, blood thinners for at-risk clients, leg exercises.
Chest tubes
Chest tubes remove air or fluid from around the lung. These questions have specific right answers.
Normal findings:
- Gentle bubbling in the suction chamber is normal if suction is on
- Tidaling — the water level in the water seal chamber moves up and down with breathing — is normal and shows the system is working
Abnormal findings:
- Continuous bubbling in the WATER SEAL chamber = an air leak. Check all connections and the insertion site.
- No tidaling may mean the lung has re-expanded, or that the tube is blocked or kinked. Assess the client.
The rules:
- Keep the drainage system below the level of the chest
- Do not routinely clamp the tube — clamping can trap air and cause a collapsed lung under pressure
- Do not strip or milk the tubing unless specifically ordered
- Keep the tubing free of kinks and loops
- Encourage deep breathing and coughing
Two emergencies:
If the tube comes out of the client’s chest: cover the site immediately with a dressing taped on three sides. This lets air escape but not enter. Notify the provider.
If the tube disconnects from the drainage system: place the end in sterile water and notify the provider.
The short version
- COPD: low oxygen is their baseline; low-flow oxygen; pursed-lip breathing
- Asthma: a silent chest is an emergency
- Pneumonia: cultures before antibiotics; prevent with turning, coughing, deep breathing
- PE: sudden shortness of breath and chest pain; sit up, oxygen, call
- Chest tubes: bubbling in the water seal = leak; keep below the chest; never clamp routinely; tube out = tape on three sides
Sources
- NCSBN. 2026 NCLEX-RN Test Plan. https://www.nclex.com/files/2026_RN_Test%20Plan_English-F.pdf
- NCSBN. Clinical Judgment Measurement Model. https://www.nclex.com/clinical-judgment-measurement-model.page
Oxygen therapy and chest tube protocols vary by facility. Follow current guidelines and provider orders.
Frequently asked questions
Common follow-up questions on Body Systems & Clinical Content.
What oxygen do you give a COPD client?
Usually low-flow oxygen, often 1 to 3 liters per minute, with the client's response monitored closely. You do not withhold oxygen from someone dangerously hypoxic (the old idea of avoiding oxygen entirely in COPD is not correct) but rates are kept low and the client is watched. Their baseline saturation may sit in the high 80s or low 90s and is not an emergency unless it is a change.
Why is a silent chest an emergency in asthma?
Because if wheezing stops and the chest becomes quiet, it is not improvement. It means almost no air is moving. The first actions are to sit the client upright, give the rescue short-acting bronchodilator, give oxygen, and stay with them.
How do you recognize a pulmonary embolism?
Sudden onset in someone with risk factors is the clue: sudden shortness of breath, sharp chest pain worse with breathing, fast heart rate, anxiety and a feeling of doom, low oxygen, and sometimes coughing blood. Risk factors include recent surgery, immobility, long travel, fractures, cancer, pregnancy, and birth control pills. Sit the client upright, give oxygen, and notify the provider immediately.
What is normal versus abnormal in a chest tube?
Gentle bubbling in the suction chamber is normal with suction on, and tidaling (the water level moving up and down with breathing) is normal and shows the system is working. Continuous bubbling in the water seal chamber means an air leak, so check the connections and insertion site, and no tidaling may mean the lung has re-expanded or the tube is blocked or kinked.
What do you do if a chest tube comes out or disconnects?
If the tube comes out of the client's chest, cover the site immediately with a dressing taped on three sides so air can escape but not enter, then notify the provider. If the tube disconnects from the drainage system, place the end in sterile water and notify the provider.
3,000+ NCLEX questions with think-like-a-nurse rationales, unfolding case studies and adaptive mock exams: free to start, no card required.
Start Free Trial →