PCCN Respiratory Review (14%): Oxygen and BiPAP Decisions, Chest Tubes and Pulmonary Embolism

The PCCN respiratory list is full of moments when a step-down patient is either stabilizing or heading for the ICU: the COPD patient on oxygen, the patient on BiPAP, the patient with a chest drain. This review covers those decisions from current clinical references. It isn't a substitute for your unit's protocols or a prescriber's orders, and it gives no doses or ventilator prescriptions.

What the PCCN respiratory category lists

The test plan in the PCCN Exam Handbook (Direct Care, July 2026) names 14 respiratory problems:

• Airways and exacerbations: severe asthma, COPD exacerbation
• Failure: acute respiratory distress syndrome, acute and chronic respiratory failure and failure to wean, respiratory depression (medication-induced or from decreased level of consciousness)
• Pleura and surgery: pleural space complications (pneumothorax, hemothorax, pleural effusion, empyema, chylothorax), minimally invasive thoracic surgery such as VATS, thoracic surgery such as lobectomy or pneumonectomy
• Vascular and parenchymal: pulmonary embolism, pulmonary fibrosis, pulmonary hypertension, connective tissue disorders such as sarcoidosis
• Other: obstructive and central sleep apnea, respiratory infections such as pneumonia

The testable nursing actions are: interpret blood gases (ABG, VBG); maintain the airway; manage patients in the prone position; manage stable, home or chronic mechanical ventilation; manage BiPAP, CPAP, face masks, high-flow therapy, nasal cannula, non-rebreather masks and Venturi masks; manage continuous SpO2 and end-tidal CO2 (capnography) monitoring; manage tracheostomy tubes and chest tubes, including pleural drains; manage patients with pulmonary artery hypertension; monitor patients before and after bronchoscopy, chest tube insertion and thoracentesis; and recognize respiratory complications and start interventions.

At 14%, the category is about 17 or 18 scored questions (Passy's arithmetic), and full prep at launch includes 118 planned Respiratory questions for this category.

Oxygen in a COPD exacerbation: how much, and how

The MSD Manual's chapter on treating acute COPD exacerbations (reviewed July 2026) makes four points about oxygen:

1. Give it. Many patients need oxygen during an exacerbation. Hypercapnia may worsen with oxygen, but oxygen is still recommended, and severe central nervous system depression is unlikely unless the PaCO2 is above 85 mm Hg.
2. Aim modestly. The target PaO2 is about 60 mm Hg. Higher levels offer little advantage and increase the risk of hypercapnia, and low concentrations usually correct the hypoxemia. A need for high concentrations suggests shunt physiology or another contributor.
3. Use a device you can regulate. In patients prone to hypercarbia (an elevated serum bicarbonate may point to a compensated respiratory acidosis), give oxygen by nasal prongs or a Venturi mask so it can be closely regulated, and monitor closely.
4. Escalate if they worsen. Patients who deteriorate on oxygen, for example with severe acidemia or central nervous system depression, need more respiratory support.

The same chapter says bronchodilators (a short-acting beta-agonist and an anticholinergic), with or without glucocorticoids, start at the same time as oxygen. It also lists features of a life-threatening exacerbation that call for ICU admission: uncorrected moderate to severe hypoxemia, acute respiratory acidosis, new arrhythmias, or deteriorating respiratory function despite hospital treatment.

BiPAP and CPAP: who is a candidate, and when it is failing

The MSD Manual's procedure chapter on noninvasive positive pressure ventilation (NPPV, reviewed November 2025) defines the two modes. CPAP keeps one constant pressure through the breath. Bilevel positive airway pressure (BPAP, often called BiPAP) is triggered by the patient's breaths, with separate inspiratory (IPAP) and expiratory (EPAP) pressures. NPPV is used mainly to delay and possibly prevent intubation.

Much of the right-hand column comes back to the airway: with NPPV it is unprotected, so the patient must be alert enough to protect it, and aspiration is a recognized complication, as is barotrauma, including pneumothorax.

Watching for failure. The chapter says to observe the patient from 30 minutes after starting BPAP, to monitor closely to identify patients who don't improve (usually within 1 to 2 hours) and may need intubation, and that serial blood gases can guide management. Decreasing alertness is an indication to convert to intubation. The COPD chapter adds that deterioration on noninvasive ventilation calls for invasive ventilation, and that high-flow nasal oxygen can be tried in patients who don't tolerate mask ventilation. The patient may sit upright or semirecumbent.

For a COPD exacerbation specifically, the COPD chapter reports that NPPV appears to reduce the need for intubation, hospital stay and mortality in severe exacerbations, defined there as a pH below 7.30 in hemodynamically stable patients not at immediate risk of respiratory arrest. Note the slight difference from the NPPV chapter's indication (PaCO2 above 45 mm Hg or pH below 7.30); both chapters treat a pH below 7.30 as a reason for NPPV.

Chest tubes and pleural drains

From the MSD Manual's thoracostomy chapter (reviewed May 2025):

• Why they are placed. Indications include a recurrent, persistent, traumatic, large, tension or bilateral pneumothorax, any pneumothorax in a patient on positive-pressure ventilation, a symptomatic or recurrent large effusion, empyema or complicated parapneumonic effusion, hemothorax and chylothorax.
• The drainage system. The tube connects to a water seal apparatus, which keeps air from entering the chest through the tube and allows drainage with or without suction; gravity assists drainage without suction. The apparatus must be kept 100 cm (40 inches) below the patient to prevent fluid or air flowing back into the pleural space.
• What goes wrong. Listed complications include malposition, blockage by clots, debris or kinking, dislodgement, bleeding, infection, re-expansion pulmonary edema and subcutaneous emphysema.
• Checking position. A bedside chest radiograph is taken after insertion.
• Removal. For a pneumothorax, suction is stopped and the tube left on water seal for several hours to confirm the air leak has stopped and the lung stays expanded. For effusions or hemothorax, removal typically follows drainage below 100 to 200 mL a day of serous fluid. The patient is semi-erect, takes a deep breath and then exhales forcibly, and the tube comes out during exhalation, with petroleum gauze over the site. A chest radiograph follows several hours later.

Bedside drain care involves more detail than this chapter covers, and it varies by drainage system and protocol. For that level of detail, the AACN Procedure Manual for Progressive and Critical Care is on the bibliography AACN uses to validate PCCN items.

Tension pneumothorax: diagnose it at the bedside

The MSD Manual's pneumothorax chapter (reviewed July 2025) describes tension pneumothorax as air that keeps entering the pleural space but can't leave, collapsing the lung, shifting the mediastinum and impairing venous return. It most commonly occurs in patients receiving positive-pressure ventilation, and the NPPV chapter lists tension pneumothorax among the barotrauma complications of noninvasive ventilation too. The chapter is direct about timing:

• Suspect it when a mechanically ventilated patient becomes suddenly hypotensive.
• Presume it if decreased breath sounds and hyperresonance to percussion are also present, and treat immediately without waiting for a chest radiograph.
• Treat it with needle decompression, followed immediately by tube thoracostomy.

In a pneumothorax generally, the affected side shows absent tactile fremitus, hyperresonance and decreased breath sounds, and a large one can shift the trachea to the opposite side. Fast recognition of patterns like this is what 65 planned Respiratory flashcards are built to drill.

Pulmonary embolism: nonspecific, so keep it on the list

The MSD Manual's pulmonary embolism chapter (reviewed November 2024) stresses that symptoms and signs are nonspecific:

• Symptoms. Dyspnea, pleuritic chest pain when there is infarction and, in more severe cases, light-headedness, presyncope, syncope or cardiorespiratory arrest.
• Signs. Tachypnea and tachycardia; significant unexplained tachycardia may be a clue, and PE should be considered in any older patient with tachypnea and altered mental status.
• Tests. Oxygen saturation can be normal, and the ECG most often shows only tachycardia and nonspecific ST-T changes; the S1Q3T3 pattern or a new right bundle branch block occurs in only about 5% of patients.
• Severity. High-risk (massive) PE means impaired right ventricular function with hypotension, defined as a systolic pressure below 90 mm Hg or a drop of at least 40 mm Hg from baseline for 15 minutes. Intermediate-risk PE has right ventricular dysfunction without hypotension, and low-risk PE has neither. When death occurs, it is often from right ventricular failure.

So a step-down patient with new, unexplained tachycardia and dyspnea deserves a PE thought even when the SpO2 looks acceptable.

Blood gases, sleep apnea and ventilated patients

• ABGs and VBGs. Interpreting both is a testable action. For a step-by-step method (primary disorder, compensation, Winter's formula, anion gap), the published CCRN ABG and acid-base guide works for PCCN patients too.
• Sleep apnea. The test plan names obstructive and central sleep apnea. The MSD Manual's chronic heart failure chapter notes that sleep-related breathing disorders are common in heart failure and can both aggravate it and be worsened by it, and the NPPV chapter notes that CPAP is often used for obstructive sleep apnea outside the hospital.
• Ventilators and proning. The PCCN list says stable, home and chronic ventilators rather than acute ICU management. For lung-protective settings and peak versus plateau pressures, the published CCRN respiratory review covers the ICU side.

Your next step for PCCN respiratory study

Write the NPPV contraindication column from memory, then check it against the table above; it is the kind of list that decides a "which patient" question. Then do a short set of the free PCCN practice questions and note which respiratory misses came from devices and which from recognition. For harder mixed sets later, full prep at launch plans Hard Mode and No-Miss Run challenges.