COPD and Respiratory
What to assess, oxygen safety in the home, inhaler technique nobody checks, and the action plan that keeps a patient out of hospital.
COPD patients bounce back to hospital because an exacerbation was recognised three days late. Most of what prevents that is teaching the patient to spot it themselves — you are there an hour a week.
Every visit
- Vital signs and pulse oximetry, at rest and after exertion — see Vital Sign Parameters — When to Call
- Work of breathing — accessory muscle use, pursed-lip breathing, tripod positioning, ability to speak in full sentences
- Breath sounds — wheeze, diminished air movement, crackles
- Cough and sputum — amount, colour, thickness, and any change from their normal
- Exertional tolerance — how far before symptoms, and how long to recover
- Inhaler and nebuliser technique — watched, not asked about
- Oxygen — flow rate against the order, tubing condition, equipment function
- Smoking status, without a lecture
- Anxiety — breathlessness and panic amplify each other
A comfortable patient at 89% may be at their baseline. A patient working hard at 93% is in more trouble. Trend and effort matter more than the number.
Find out and record their baseline SpO2. Without it, nobody covering your caseload can tell whether today's reading means anything.
Inhaler technique
The highest-yield five minutes you will spend. A large share of patients get little or no drug from their inhaler, and nobody has ever watched them use it.
- Watch them take a full dose with their own device
- Spacer with any MDI where one is indicated — and check they have one
- Different devices need opposite techniques: slow and deep for an MDI, quick and forceful for most dry powder inhalers
- Order matters — bronchodilator before inhaled steroid
- Rinse and spit after inhaled steroids to prevent thrush
- Check whether the canister is actually empty — many have no dose counter
- Confirm they can tell the rescue inhaler from the maintenance one, and know when each is used
Confusing rescue and maintenance is common and consequential. Have them show you which is which.
Oxygen in the home
Safety, which is not optional:
- No smoking in the home — by anyone, and this includes visitors
- No open flame, gas stoves, candles, or space heaters near the oxygen
- Tubing not run under rugs or through doorways where it will be crushed or tripped over
- Cylinders secured upright, never stored in a closet or car boot
- Working smoke detectors
Function:
- Flow rate matches the order — check the dial, do not assume
- Tubing length, condition, and no kinks
- Concentrator filter clean, air intake unobstructed
- Cylinder backup available, and the patient knows how to switch over — see Emergency Preparedness and Acuity Tiers
- Patient and caregiver know the DME supplier's emergency number
The smoking-with-oxygen conversation rarely works as an instruction. Talk about where and when, involve the family, offer cessation support, and document what you advised and the response.
Teaching that prevents readmission
Pursed-lip and diaphragmatic breathing
Teach it while they are calm, practise it until it is automatic, so it is available when they are not. Breathe in through the nose for two, out through pursed lips for four.
Energy conservation
This is where an OT referral earns its place, and it is the most under-used referral in home health for this group. Sit to dress and to wash. Put frequently used things at waist height. Pace tasks with rest between. Use a shower chair. Exhale on exertion.
The action plan
Patients do far better with a traffic-light plan they can apply without you.
| What it looks like | What to do | |
|---|---|---|
| Green | Usual breathing, usual cough and sputum, usual activity | Carry on; take maintenance medications |
| Yellow | More breathless than usual, more or thicker sputum, colour change, using rescue inhaler more, less activity, sleeping poorly | Call us or the physician today; start the action plan if one is ordered |
| Red | Severe breathlessness at rest, cannot speak in sentences, chest pain, blue lips or fingers, confusion, drowsiness | Call 911 |
Write it down and leave it where they will see it — on the fridge, not in a folder.
When to call
- SpO2 below the ordered threshold, or a sustained drop from their baseline
- Increased work of breathing
- Change in sputum colour, volume, or thickness — often the first sign of infection
- Fever
- New or worsening ankle swelling — consider cor pulmonale
- Confusion or unusual drowsiness, which may mean CO₂ retention
- Rescue inhaler being used far more than usual
911 for severe respiratory distress, chest pain, cyanosis, or altered mental status.
Where the episode goes wrong
- Nobody watched the inhaler technique. The most common unfixed problem in COPD care.
- The exacerbation was recognised late because the patient had no yellow-zone signs to watch for.
- Oxygen is worn only when they feel breathless, rather than as ordered.
- Deconditioning is treated as progression. A patient who stopped moving because they were breathless gets weaker, then more breathless. PT is often the answer, not more oxygen.
- Anxiety went unaddressed. Breathlessness causes panic, panic worsens breathlessness, and neither improves until both are named.