chapter 28: obstructive pulmonary disease Flashcards
COPD: what it is and what it isn’t
-preventable, but usually progressive disease
-limits airflow
-inflammation of airways and lungs and pulmonary blood vessels
NOT
-chronic bronchitis = cough + sputum for 3 months; 2 yrs in a row
-Emphysema = destruction of alveoli w/o fibrosis
*more men get it, but its worse for women
Risk factors for COPD: cigarettes
-Hyperplasia of cells, reducing airway diameter
-fucks with cilia
-dilates distal airway, messing up alveoli
-precancerous cells
-“remodeling” = chronic inflammation in lungs
-oxidative stress + protease imbalance (even after you’ve quit)
*secondhand smoke causes damage too
Risk for COPD: infections
-recurring respiratory infections from childhood
-HIV ppl get it faster
-TB is risk
Risk for COPD: asthma, air pollution, occupational chems
-lots of overlap bt asthma and COPD
-air pollution MIGHT be a risk factor
-coal and biomass fuels are deffinitely risk factors
-occupational exposure to smoke/chems is bad
Risk for COPD: aging and genetics
unclear whether aging is a factor
effects of aging:
-loss of elasticity/recoil
-stiffening of chest wall and rib mobility
-rounding of rib cage due to increased residual volume
-less alveoli as peripheral airways lose supporting tissue
-genes are a maybe –> some smokers get COPD, others don’t
Risk for COPD: Alpha-1 Antitrypsin Deficiency (AATD)
-autosomal recessive disorder that affects lungs and liver
-AAT is made by liver and found in lungs and inhibits alpha proteases during inflammation
-severe AATD causes premature bullous emphysema in lungs –> smoking makes it worse
What even is COPD?
airflow restriction bc loss of recoil and obstruction –> mucus, edema, bronchospasms
-progresses to pulmonary hypertension and systemic manifestations
-Inability to expire air
Inflammation process of COPD
-neutrophils, macrophages, and lymphocytes attract leukotrienes and proinflammatory cytokines
-oxidants make it worse –> increase protease activity (breakdown CT) and decrease antiprotease activity (protection)
Explain barrel chestedness/emphysema of COPD
alveolar attachments to small airways are destroyed, trapping air in lungs and increasing functional residual capacity
makes passive respiration difficult –> becomes dyspneic with little exercise
hypoxemia in COPD
-doesn’t happen at rest until late stages
-often issues during excercise –> give O2
As disease worsens, air trappings increase, alveolar walls get destroyed, and bullae/blebs form –> poor gas exchange
**Bullae not a/w capillaries
**hypercapnia is major issue
COPD mucus
-only present if predominant chronic bronchitis
caused by
-more goblet cells
-bigger submucosal glands
-cilia dysfunc
-stimulation f/ inflammatory mediators
systemic changes w/ COPD
-osteoporosis, diabetes, metabolic syndrome, and CV disease
pulmonary vascular issues
-arteries constrict bc of hypoxia
-smooth muscle thickens
-more pressure on vessels due to expansion of dysfunctional alveoli
-Right ventricle hypertroohy and possibly right HF
Classification of COPD
GOLD 1 = mild = FEV > 80%
GOLD 2 = moderate = FEV 50-80%
GOLD 3 = severe = FEV 30-50%
GOLD 4 = very severe = FEV <30%
Manifestations/Progression of COPD
cough (productive or not)
difficulty getting full breaths
dyspnea (constant) –> starts affecting ADLS
-lungs overinflate (emphysema), diaphragm flattens –> chest breather (inefficient)
-wheezing and chest tightness
-fatigue, anorexia, weight loss
-hypoxemia, hypercapnia, polycythemia, cyanosis
-high Hemoglobin, but low other stuff
Complications of COPD: pulmonary HTN and Cor Pulmonale
-erythropoiesis causes polycythemia, increasing blood viscosity
-Right hypertrophy and failure
-S3, S4, murmurs, big liver, and water retension
Give O2, maybe diuretics, and anticoagulants
Complications of COPD: Acut exacerbations
-usually due to bacterial or viral infection
MORE DYSPNEA, SPUTUM, AND PURULENCE
-happen more frequently as disease progresses
-typically depressed and confused
look for severe symptoms:
-accessory muscle use, central cyanosis, edema, altered alertness, unstable BP
Give SABAs and coricosteroids –> give O2 w/ as little invasion as possible
Complications of COPD: ARF
happens bc of severe exacerbations or suddenly stopping bronchodilator/corticosteroids
Diagnostic studies of COPD
Spirometry!!!!!
-Saba and Fev1/FVC ratio –> bad if under 70%
chest xrays not really helpful
-put patient on room air if SaO2 < 88% at rest
ABG and ECG
How to care for COPD patient
-influenza and pneumonia vaccine
-Smoking cessation
-if mild, SABA and bronchodilators (albuterol and/or ipratropium)
-if moderate (FEV<60%), add LABA and possibly ICSs and anticholinergics
Surgery (not everyone’s a candidate)
-lung volume reduction surgery –> removes bad parts and allows diaphragm to return to normal
-bronchoscopic lung volume reduction surgery –> uses 1 way valve to shut down fucked up parts of lung
-bullectomy
-lung transplant
Oxygen therapy COPD
-keep SaO2 above 90% and PaO2 above 60
-low flow (includes room air) or high flow (venturi mask)
-humidify the oxygen to prevent irritation
Complications of oxygen therapy
-combustion
-CO2 narcosis = tolerance to CO2 makes hypoxia main drive to breathe, so its dangerous to give O2 –> monitor vitals, ABG, and mental state
-O2 toxicity = O2 free radicals damage alveoli further, causing pulmonary edema, shunting of blood, and hypoxemia
Infection = from heated nebulizers cultivating pseudomonas aeruginosa
Oxygen therapy at home
-its a thing
-often given only during excersise or at night
-improved surival if use long term O2 therapy (over 15 hr/day)
-reevaluate every 1-3 months
-small prtable O2 if patient active outside home
-respiratory therapist comes and helps
-if traveling, make sure always have access to O2
Breathing retraining COPD
-teach pursed lips breathing and diaphramatic breathing
-PLB = “just enough” pressure through pursed lips to prolong exhalation
-diaphragmatic breathing = slows respiratory rate and allows for maximum inhalation (might increase WOB and dyspnea though)
Airway clearance techniques
coughing –> huff coughing
chest physiotherapy
airway clearance devices
high frequency chest ventilation
Given by resp therapists, physical therapists, and nurses
USUALLY ADMINISTER BRONCHODILATOR THERAPY FIRST
Components of Chest physiotherapy (CPT)
-used for ppl w/ bronchial secretions who can’t clear them
- Postural drainage –> get secretions into larger airways
-if can’t do head down, use side-lying
-do for 5 mins, 2-4x a day while percussing and vibrating - Percussion = in cupped-hand position w/ fingers and thumbs closed –> do over fabric
- vibration
Airway clearance devices
-easier to tolerate and faster than CPT sessions
-E.g. Flutter, Acapella, TheraPEP
-use positive expiratory pressure (PEP)
Flutter = handheld, steel ball in cone, vibrates with breath, good for mucus
Acapella = handheld –> can be used in any position
TheraPEP = inhale aerosols; exhale with PEP
High frequency chest wall oscilation
25-30 lb vibrating vest
Nutritional therapy: COPD
COPD ppl are underweight in late stages bc high inflammation + metabolic rate–> also chane in taste bc mouth breathing
Rest before eating –> might feel full off small amounts bc changes in chest/diaphragm
High cal; high prot; moderate carb
Old people and COPD
-less muscle mass/ breathing strength
-very bad if there’s comorbidities
-need drugs to manage acute exacerbations
-don’t use beta blockers or ace inhibitors
-sometimes there’s accidental noncompliance also issues w/ MDIs
Try to improve their quality of life
COPD Health promotion
-Tell ppl to stop smoking –> like fr
-Tell ppl w/ COPD to avoid sick ppl and excersise regularly
-get vaccinated
-avoid irritants
-know that COPD and AATD are genetic
Pulmonary rehab
Physical therapist or nurse
inpatient, outpatiet, or at home
relieves dyspnea/fatigue and gives patients a sense of control
Activity considerations COPD
-excersise upper extremeties
-go on walks with pursed lips –> shouldn;t take >5 mins to return to baseline
Save energy everywhere else
-get OT to teach you how to do stuff
-sit and have O2 while performing hygiene activities
Don’t move! especially not to a place of high elevation
What to do with anxious COPD person
-give Buspirone, SABA, or advise pursed lips
Dont give Benzodiazepines
How should COPD ppl have sex?
-plan for part of day when breathing is best
-pursed lips
-not after alc
-don’t do difficult positions
-use O2 maybe
***might be mixed w/ normal complications of getting old
Sleep COPD
-O2 and RR might drop while sleeping = hypercapnia = waking up
-Beta2 agonists are bad
-postnasal drip or congestion might cause wheezing or coughing –> saline spray
Cure for COPD
doesn’t exist!
