2.3 COPD Flashcards
Tidal volume
normal breathing (in and out)
Vital capacity
max amount of air exhaled following max inhalation
Functional residual volume
elastic recoil forced of the lungs the chest walls are at equilibrium and no exertion by diaphragm or other respiratory muscles
With COPD FRV increases. T/F
True
Breathing in and out at higher FRV
As FRV goes up, VC goes down. T/F
True
What is the most common respiratory with acute exacerbations?
COPD
85% of chronic dyspnea if caused by:
CHF MI Asthma COPD ILD PNA Psychogenic disorders
COPD
Is often missed or misdiagnosed due to S&S! People begin to limit activities so they don’t get these effects…
Worsening of SOB
Phlegm-Producing cough and episodes of wheezing
Paroxysmal atrial is may be normally seen post-op. T/F
True
When is oxygen recommended for a patient?
PaO2 <60, SaO2 90%
not enough oxygen perfusing brain and system!
People may be adapted to live in lower levels…88% if hx, look at S&S!
Ideally what do we want our pt’s SaO2 to be?
92%
What is the PaO2, SaO2 rule?
40mmHg, 70%
50, 80%
60, 90%
If someone is at 88% SaO2 with CHF, do we like that?
No…perfusion problem getting to the bloodstream
Has pulmonary edema! They’re not live normally an and is in a hypoxemic state!!
If someone is at 88% (a little short 92%) SaO2 with COPD and lives there…
Talk to medical team where they want them. Check S&S.
May live in this state if they’re used to it chronically…
When someone is 79% am I concerned?
YES
Tachypnea with high RR caused by:
1) Increased respiratory drive (response to amount of increase CO2/ drop pH levels)
2) Impaired ventilatory mechanics (not using diaphragm, flattened chest, airways restricted due to mucus or hyperinflated, morphological changes!
Pulmonary Etiology?
Increase:
More accessory muscles
SBP
RR
Decrease:
SaO2
Normal BNP
Cardiac Etiology?
Increase:
RR
BNP
Decrease:
Less accessory muscle
SBP
Normal SaO2
Chart review:
General PMH Medications? Family hx? Social? Smoking? Drug or alcohol? Susceptible to infection? Think about prior hospital stay...
Key Subjective:
Confirm CC is SOB/Dyspnea
New problem or an exacerbation or chronic condition
Precipitated the problem
What makes you feel more/less breathless?
Inhalers/nebulizers more than normal?
Previous similar episodes?
Check cognitive status due to hypoxemia!
Chest x-ray is performed to r/o
heart or lungs!
What do pulmonary tests tell us?
Overview of function of the lungs…
FEV1 - used to only look at this…
We look at FVC and FEV1!
FEV1/FVC NORMAL IS 75%
Tells you their severity of disease, but doesn’t tells you your patient’s activity tolerance/SOB.
<70% is COPD
Doesn’t tell you entire picture!!!
What stays relatively normal throughout progression of diseases?
Tidal volume, the last thing that changes as disease progression
When would you not treat a patient w/ COPD?
If they are hypoxic! <80% SaO2… Talk to team if their giving him oxygen and doing ABGs… Wait for new lab values.
Non-rebreather mask
Let’s you breath out but not in. Supposed to deliver 100% FiO2, but doesn’t due to seal on face. About 70%…
Nasal canola can deliver up to how many liters?
6L
What are physical clues that suggests emphysema?
Subcutaneous emphysema
Leaning forward w/ UE’s in closed chain (max accessory muscle use)
What are some observations seen in COPD pts?
Stridor Accessory muscles Sit upright (better than supine b/c V/Q matching is better) Expiratory wheeze Inability to speak in whole sentences
Can COPD patients have chest pain?
Yes, but differentiate if it’s muscular from breathing or cardiac!!
Hypothesis of Key Impairments:
Poor breathing mechanics Poor oxygen transportation Aerobic reconditioning Respiratory muscle weakness and fatigue Decreased functional strength/power Decreased functional mobility
With COPD you want to help them successfully breathe so during Objectives you should perform Interventions as well! T/F
True
COPD
Induced SOB
Anxiety, panic attacks
Increased SOB and anxiety
Reduced activity, fatigue
Treatments for COPD
Pursed-lip breathing
Deep breathing
If a patient is 88-90% what should be our treatment?
Breathing exercises! Don’t panic and call the nurse.
Pursed-lip breathing
Breathing out gently through pursed lips
Delay closure of small airways through PEP
Longer expiration slowing RR
Decrease work of ventilatory pump
Decrease anxiety
Apply to functional activities
Minimizing dynamic hyperinflation w/ exercise
Deep breathing: D2 pattern ventilation
Inspiration:
Trunk extension
Shoulder flexion, abduction, ER
Looking up
Expiration:
Trunk flexion
Shoulder extension, adduction, IR
Looking down
Peak expiratory flow rate
Gives you info about expiratory flow
Outpatient
or
PEFR meter
FEV meter
The taller you are the higher the PEFR (L/min)
True
Associated degree of obstruction w/ FEV1
Little or no obstruction: FEV1>2.0 L to normal
Mild to Mod: FEV1 1.0-2.0 L
Severe: FEV1 <1.0 L
Staging of COPD (FEV1), The American Thoracic Society
Predicts mortality/progression
Stage 1: FEV1 50-79% predicted
Stage 2: FEV1 35-49% predicted
Stage 3: FEV1 <35% predicted
GOLD
Stages the disease based on presentation of cough, SOB, clinical signs, looks more into limitations and FEV1 too
What medical intervention is appropriate included as well!
Stages of GOLD: 1
Smoker’s cough, little or no SOB, no clinical signs of COPD, FEV1 >80% predicted
Stages of GOLD: 2
SOB on exertion, sputum-producing cough, some clinical signs of COPD, FEV1 50-80% predicted
Stages of GOLD: 3
SOB on mild exertion, FEV1 30-50% predicted
Stages of GOLD: 4
SOB on mild exertion, R HF, cyanosis, FEV1 <30% (50% chance of dying within 2 years)
New index: BODE
Looks at function of the patient, more than just FEV1, predicts prognosis, outcomes, and chances/incidence of re-hospitalization.
BODE: (4 variables)
1) BMI
2) Airway Obstruction (FEV1)
3) Dyspnea (Medical Research Council dyspnea score)
4) Exercise capacity (6MWT)
(BODE) MMRC Index score and approximate 4-year survival rate
0-2: 80% survival
3-4 67% survival
5-6: 57% survival
7-10: 18% survival
RT
Consider timing after RT to help patient be more successful!
Diaphragmatic breathing
Comfortable position, drawing awareness to abdominal wall, plating for abdominal excursion during inspiration at tidal volume.
Sidelying, semi-fowler, supine, sitting, standing, walking, stairs
4 steps of a cough:
1) adequate inspiration
2) glottal closure
3) building up intrathoracic and intraabdominal pressure
4) Glottal opening and expulsion
Assisted cough technique
Utilize firm pillow, towel roll, or hands to splint for self-assisted cough
*Exaggerate with arms overhead
Huff assessment
Forced exhalation w/o maximal effort, that can be utilized to mobilize secretions from peripheral airways
Inhale, hold 2-3s, breathe out slowly and forcefully
(fogging mirror)
Effective huffing
Mouth open, O-shaped to keep glottis open, sigh
Crackles heard, excess present
Ineffective huffing
Mouth half or almost closed, mouth shaped for E sound, hissing/blowing
Promote posterior pelvic tilt
facilitates diaphragmatic breathing
*towel under ischial tuberosities
Minimize anterior pelvic tilt
Avoid excessive opening of the anterior chest which leads to upper chest breathing and restricts diaphragmatic excursion
Repatterining technique: sniff activation
simple and effective method of teaching diaphragmatic breathing, act of sniffing
progression - focus on slow inhalation holding the breath in, and slow exhalation through pursed-lip… then decrease pursed-lip
Facilitation Techniques: Lateral costal breathing, Segmental breathing
Facilitates diaphragmatic excursion and may be done bilaterally, or unilaterally
*Gently apply pressure against ribs during inspiration, and/or quick stretch before inspiration and continue to give pressure during inspiration
Facilitation Techniques: Upper chest inhibiting
inhibits the upper chest to help pt recruit diaphragm during inhalation
*LAST option
Facilitation Techniques: Thoracic mobilization
if mobility of thoracic is restricted, helps patient move through breathing pattern if they can’t control it
- Towel roll vertically on TS, improves anterior chest wall mobility
- Sidelying improves lateral chest wall mobility
- Add D2 for mobility
