chapter 28: obstructive pulmonary disease

Question 1

COPD: what it is and what it isn’t

Answer 1

-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

Question 2

Risk factors for COPD: cigarettes

Answer 2

-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

Question 3

Risk for COPD: infections

Answer 3

-recurring respiratory infections from childhood
-HIV ppl get it faster
-TB is risk

Question 4

Risk for COPD: asthma, air pollution, occupational chems

Answer 4

-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

Question 5

Risk for COPD: aging and genetics

Answer 5

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

Question 6

Risk for COPD: Alpha-1 Antitrypsin Deficiency (AATD)

Answer 6

-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

Question 7

What even is COPD?

Answer 7

airflow restriction bc loss of recoil and obstruction –> mucus, edema, bronchospasms
-progresses to pulmonary hypertension and systemic manifestations
-Inability to expire air

Question 8

Inflammation process of COPD

Answer 8

-neutrophils, macrophages, and lymphocytes attract leukotrienes and proinflammatory cytokines
-oxidants make it worse –> increase protease activity (breakdown CT) and decrease antiprotease activity (protection)

Question 9

Explain barrel chestedness/emphysema of COPD

Answer 9

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

Question 10

hypoxemia in COPD

Answer 10

-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

Question 11

COPD mucus

Answer 11

-only present if predominant chronic bronchitis

caused by
-more goblet cells
-bigger submucosal glands
-cilia dysfunc
-stimulation f/ inflammatory mediators

Question 12

systemic changes w/ COPD

Answer 12

-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

Question 13

Classification of COPD

Answer 13

GOLD 1 = mild = FEV > 80%
GOLD 2 = moderate = FEV 50-80%
GOLD 3 = severe = FEV 30-50%
GOLD 4 = very severe = FEV <30%

Question 14

Manifestations/Progression of COPD

Answer 14

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

Question 15

Complications of COPD: pulmonary HTN and Cor Pulmonale

Answer 15

-erythropoiesis causes polycythemia, increasing blood viscosity
-Right hypertrophy and failure
-S3, S4, murmurs, big liver, and water retension

Give O2, maybe diuretics, and anticoagulants

Question 16

Complications of COPD: Acut exacerbations

Answer 16

-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

Question 17

Complications of COPD: ARF

Answer 17

happens bc of severe exacerbations or suddenly stopping bronchodilator/corticosteroids

Question 18

Diagnostic studies of COPD

Answer 18

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

Question 19

How to care for COPD patient

Answer 19

-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

Question 20

Oxygen therapy COPD

Answer 20

-keep SaO2 above 90% and PaO2 above 60
-low flow (includes room air) or high flow (venturi mask)
-humidify the oxygen to prevent irritation

Question 21

Complications of oxygen therapy

Answer 21

-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

Question 22

Oxygen therapy at home

Answer 22

-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

Question 23

Breathing retraining COPD

Answer 23

-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)

Question 24

Airway clearance techniques

Answer 24

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

Question 25

Components of Chest physiotherapy (CPT)

Answer 25

-used for ppl w/ bronchial secretions who can’t clear them

1. 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
2. Percussion = in cupped-hand position w/ fingers and thumbs closed –> do over fabric
3. vibration

Question 26

Airway clearance devices

Answer 26

-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

Question 27

High frequency chest wall oscilation

Answer 27

25-30 lb vibrating vest

Question 28

Nutritional therapy: COPD

Answer 28

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

Question 29

Old people and COPD

Answer 29

-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

Question 30

COPD Health promotion

Answer 30

-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

Question 31

Pulmonary rehab

Answer 31

Physical therapist or nurse
inpatient, outpatiet, or at home
relieves dyspnea/fatigue and gives patients a sense of control

Question 32

Activity considerations COPD

Answer 32

-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

Question 33

What to do with anxious COPD person

Answer 33

-give Buspirone, SABA, or advise pursed lips

Dont give Benzodiazepines

Question 34

How should COPD ppl have sex?

Answer 34

-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

Question 35

Sleep COPD

Answer 35

-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

Question 36

Cure for COPD

Answer 36

doesn’t exist!