Chapter 28 Obstructive Pulmonary Diseases Flashcards
1
Q
- Asthma is a heterogenous disease characterized by a combination of clinical manifestations along with?
- The variability of signs and symptoms can include episodes of?
- These episodes are associated with widespread but variable airflow obstruction that is usually reversible, either spontaneously or with treatment. The clinical course of asthma is unpredictable, ranging from?
A
- reversible expiratory airflow limitation or bronchial hyperresponsiveness.
- wheezing, breathlessness, chest tightness, and cough, particularly at night or in the early morning.
- periods of adequate control to exacerbations with poor control of symptoms
2
Q
What is asthma?
A
Asthma is a chronic inflammatory disorder of the airways that results in recurrent episodes of airflow obstruction that it is usually reversible
3
Q
The primary pathophysiologic process in asthma is persistent but variable?
A
inflammation of the airways. The airflow is limited because the inflammation results in bronchoconstriction, airway hyperresponsiveness (hyperreactivity), and edema of the airways
4
Q
1) Although the exact mechanisms that cause asthma remain unknown, often exposure to a trigger, such as an allergen or irritant, initiates the?
2) precipitating factors of an acute asthma attack.
3) Asthma is not a?
A
1) inflammatory cascade.
2) Respiratory infections are also precipitating factors of an acute asthma attack.
3) Asthma is not a psychosomatic disease.
5
Q
Genetics and?
A
one’s immune responses may influence asthma development.
6
Q
Common allergens include?
A
tree or weed pollen, dust mites, molds, furry animals, and cockroaches.
7
Q
exercise-induced asthma
A
Asthma that is induced or exacerbated after physical exertion
8
Q
Various air pollutants, cigarette or wood smoke, vehicle exhaust, elevated ozone levels, sulfur dioxide, and nitrogen dioxide can trigger asthma attacks. The role of outdoor air pollution as a cause of asthma is controversial.
A
.
9
Q
Occupational asthma occurs?
A
after exposure to agents in the workplace. These agents are diverse and include wood dusts, laundry detergents, metal salts, chemicals, paints, solvents, and plastics.
10
Q
- Most patients with asthma have a history of?
- what is more common in persons with asthma?
A
- allergic rhinitis.
- Gastroesophageal reflux disease (GERD) is more common in persons with asthma.
11
Q
Certain drugs may?
A
precipitate asthma
12
Q
The characteristic clinical manifestations of asthma are?
A
wheezing, cough, dyspnea, and chest tightness, particularly at night or early in the morning. Expiration may be prolonged. Examination of the patient during an acute attack usually reveals signs of hypoxemia
13
Q
Asthma can be classified as?
A
intermittent, mild persistent, moderate persistent, or severe persistent, based upon current impairment of the patient and their risk for exacerbations.
14
Q
Severe exacerbations of asthma can result in complications such as?
A
severe hypoxia, “silent chest,” and peak flow less than 40% of personal best.
15
Q
A diagnosis of asthma is usually made based upon the?
A
presence of various indicators (i.e., clinical manifestations, health history, spirometry, peak flow variability)
16
Q
- The goal of asthma treatment is to?
- Established guidelines give direction on the classification of severity of asthma at initial diagnosis and help determine?
A
- achieve and maintain control of the disease.
- which types of medications are best suited to control the asthma symptoms.
17
Q
Asthma: A stepwise approach to drug therapy is based initially on the?
- Persistent asthma requires?
- Even persons with intermittent asthma should always carry?
A
- asthma severity and then on level of control.
- long-term (controller) therapy in addition to appropriate medications to manage acute symptoms (rescue).
- rescue medication
18
Q
Asthma Medications are divided into two general classifications:
A
(1) long-term–control medications to achieve and maintain control of persistent asthma
(2) quick-relief (rescue) medications to treat symptoms and exacerbations
19
Q
Because chronic inflammation is a primary component of asthma, what drugs are used?
A
inhaled corticosteroids are more effective in improving asthma control than any other long-term drug. Inhaled (ICS) agents, such as fluticasone (Flovent) and budesonide (Pulmicort), are first-line therapy for patients with persistent asthma.
20
Q
Orally administered corticosteroids are indicated for?
A
acute exacerbations of asthma. Maintenance doses of oral corticosteroids may be necessary to control asthma in a minority of patients with severe chronic asthma.
21
Q
Short-acting inhaled β2-adrenergic agonists, including albuterol, are?
A
the most effective drugs for relieving acute bronchospasm. They are also used for acute exacerbations of asthma.
22
Q
Long-acting inhaled β2-adrenergic agonists, including salmeterol (Serevent) and formoterol (Foradil), are?
A
never to be used as monotherapy in asthma due to an increased risk of death. However, they are quite safe when combined with ICS such as fluticasone/salmeterol (Advair) or budesonide/formoterol (Symbicort).
23
Q
Leukotriene modifiers can be used in?
A
milder asthma successfully as add-on therapy to reduce the dose of inhaled corticosteroids.
24
Q
The only anti-IgE drug, which is omalizumab (Xolair), is used for?
A
difficult to treat moderate to severe asthma unable to be controlled by inhaled corticosteroids.
25
Methylxanthine (theophylline) preparations are?
less effective long-term control bronchodilators as compared with β2-adrenergic agonists and carry a high incidence of side effects.
26
Anticholinergic agents are?
not used in asthma treatment, except for ipratropium (Atrovent), which is only used in the ED for acute attacks.
27
The overall goals are that the patient with asthma will have asthma control as evidenced by?
minimal symptoms during the day and night, acceptable activity levels (including exercise and other physical activity), maintenance greater than 80% of personal best peak expiratory flow rate (PEFR) or forced expiratory volume in 1 second (FEV1), few or no adverse effects of therapy, no recurrent exacerbations of asthma, and adequate knowledge to participate in and carry out management.
28
Asthma: Education remains the cornerstone of asthma management. Your role in preventing asthma attacks or decreasing the severity focuses primarily on?
teaching the patient and caregiver.
29
One of the major factors determining success in asthma management is the correct administration of drugs.
♣ Inhalation devices include?
♣ Teaching should include information about medications, including the?
♣ Several nonprescription combination drugs are available over the counter. An important teaching responsibility is?
♣ Inhalation devices include metered-dose inhalers, dry powder inhalers, and nebulizers.
♣ Teaching should include information about medications, including the name, purpose, dosage, method of administration, schedule, side effects, appropriate action if side effects occur, how to properly use and clean devices, and consequences for breathing if not taking medications as prescribed.
♣ Several nonprescription combination drugs are available over the counter. An important teaching responsibility is to warn the patient about the dangers associated with nonprescription combination drugs.
30
A goal in asthma care is to maximize the ability of the patient to safely manage acute asthma episodes via an asthma action plan developed in conjunction with the HCP. An important nursing goal during an acute attack is to?
decrease the patient’s sense of panic.
31
Develop written asthma action plans together with the patient and family, especially those with?
moderate or severe persistent asthma or a history of severe exacerbations.
32
Asthma
- What is it?
- common manifestation
- Chest?
- Cough
- Risk factors
- Chronic airway inflammation
- Wheezing
- Chest tightness
- Cough
- Risk factors
* Immune response
* Allergens
* Exercise
* Pollutants
* Occupational factors
* Respiratory infections
* Nose and sinus problems
33
Patho of asthma
- Bronchospasm
- Narrows air passage
- Airflow further interrupted by increased mucous
- Swelling of bronchial tubes
- In an attack- airflow decreases
* Trapping gas
* Alveoli hyper inflate
* Atelectasis can occur
* Increased airway resistance-
* Labored breathing
34
Diagnostic tests for asthma
1) Pulmonary function tests
- Reveal signs of obstructive airway disease, vital capacity
2) ABG’s
- Determines CO2
3) Chest xray
- Shows lung hyperinflation, atelectasis
4) Skin testing
- allergens
35
Asthma treatment
- Rapid acting epinephrine
- Long or short acting beta agonists- serevent/maxair
- Theophylline
- Corticosteroids
- Leukotriene receptor modifiers to block inflammation- Singular
36
The primary pathophysiologic process in asthma is persistent but variable airway inflammation. The airflow is limited because the inflammation results in?
Bronchoconstriction, airway hyperresponsiveness (hyperactivity), and airway edema. Exposure to allergens or irritants initiates the inflammatory cascade
37
1) As the inflammatory process begins, mast cells in the broncial wall release multiple inflammatory mediators including leukotrienes, histamine, cytokines, prostaglandins, and nitric oxide
2) Inflammatory mediators have effects on the (1) blood vessels, causing vasodilation and increasing capillary permeability (running nose) (2) nerve cells, causing itching (3) smooth muscle cells, causing broncial spasms and airway narrowing (4) goblet cells causing mucous production
3) the early phase response in asthma can occur within 30-60 minutes after exposure to a trigger or irritant
4) Symptoms can occur 4-6 hours after the early response because of the influx of many inflammatory cells and the further release of more inflammatory mediators. This late phase response occurs in about 50% of people with asthma
5) Bronchoconstriction with symptoms persist for 24 hours or longer. Corticosteroids are effective in treating this inflammation
.
38
Asthma: Chronic inflammation may result in structural changes in the bronchial wall known as remodeling. A progressive loss of?
lung function occurs that is not prevented or fully reversed by lung therapy.
39
During an asthma attack, decreased perfusion and ventilation of the alveoli and increased alveolar gas pressure lead to ventilation perfusion abnormalities in the lungs.
- The patient is hypoxemic early on, with decreased partial pressure of CO2 in arterial blood (PaCO2) and increased pH caused by hyperventilation (respiratory alkalosis)
- As the airflow limitation worsens with air trapping, the PaCO2 increases to produce respiratory acidosis, which is an ominous sign of respiratory failure
40
Clinical manifestations of asthma
| S/S differ for each patient. The most common manifestations include
cough, SOB, dyspnea, wheezing, chest tightness, and variable airflow obstruction. Presence of any of these (usually in combination) can indicate that an asthma episode or attack is occurring. Attacks may last for a few minutes to several hours.
41
Characteristic manifestations of asthma are?
Wheezing, cough, dyspnea, and chest tightness. Expiration may be prolonged, with an inspiratory/expiratory ratio of 1:3 or 1:4
42
Asthma: Wheezing is an unreliable sign to gauge the severity of an attack because?
Many patients with minor attacks wheeze loudly, whereas others with severe attacks do no wheeze
43
In some patients with asthma, what is the only symptom?
Cough. The cough may be non-productive because secretions may be so thick, tenacious, and gelatinous that their removal is difficult
44
During an acute asthma attack, the patient usually?
Sits upright or slightly bent forward, using accessory muscles of respiration. The more difficult the breathing becomes, the more anxious the patient feels
45
Asthma: Signs of hypoxemia include?
Restlessness, increased anxiety, inappropriate behavior, and increased pulse and BP
46
Asthma: Percussion reveals?
Hyperresonance of the lungs. Auscultation indicates inspiratory or expiratory wheezing
47
Asthma: Diminished breath sounds may indicate?
A significant decrease in air movement. Severely diminished breath sounds or a "silent chest" is an ominous sign, indicating severe obstruction and impending respiratory failure
48
Classification of asthma
Can be classified as intermitten, mild persistent, moderate persistent, or sever persistent. This system is used to determine the Tx. Patients may have different asthma classifications over the course of the disease.
49
Asthma complications
In severe asthma exacerbations, the patient is dyspneic at rest and speaks in single words because of the difficulty breathing.
- The patient is often agitated, sitting forward to maximize the diaphragmatic movement and using accessory muscles in the neck to lift the chest wall. Respiratory manifestations are?
- Prominent wheezing may progress to?
- rate may be >30 breaths/min and pulse >120 beats/min. The peak flow (PEFR [Peak expiratory flow rate]) is 40% of the patients personal best, or <150 mL
- no apparent wheezing if the airflow is exceptionally limited. The absence of a wheeze (i.e. silent chest) in a patient who is obviously struggling to breath is a life-threatening situation that may require mechanical ventilation
50
Asthma diagnostic studies:
Underdiagnosis of asthma is common. In general, the HCP should consider a diagnosis of asthma if various indicators (i.e. clinical manifestations, health history, peak flow variability, or spirometry readings) are positive.
- Detailed history helps to identify asthma triggers
- Spirometry determines the reversibility of bronchoconstriction and thus establishes the diagnosis of asthma
- Sputum specimen can be used to rule out bacterial infection
- Serum immunoglobulin E (IgE) levels and eosinophil count, when elevated, are highly suggestive of allergic tendency
- Chest X-Ray during an attack shows hyperinflation
- Spirometry, oximetry, and arterial blood gases (ABGs) provide information about the severity of the attack and response to treatment
- Allergy skin testing can be used to determine sensitivity to specific allergens
51
Interprofessional care for asthma
The goal of asthma treatment is to achieve and maintain control of the disease. At initial diagnosis, a patient may have severe asthma and require asthma medication. After treatment, the patient is assessed for?
- Achieving rapid control of the symptoms is the goal in order to return the patient to daily functioning at the best possible level. The level of control is determined by the?
- level of asthma control. The HCP steps down the medication as the patient achieves control of the symptoms or steps it up as the symptoms worsen
- patients spirometry results and any exacerbations or adverse treatment effects
52
Intermittent and persistent asthma
The classification of asthmas severity at initial diagnosis helps determine which types of medications are best suited to control the symptoms
- Patients in all classifications of asthma require a?
- Patients with persistent asthma must also be on a?
- for long-term control of moderate to severe persistent asthma, what medications are used?
- rescue medication for short-term, immediate control of symptoms. Short acting B2-adrenergic agonists (SABA) (e.d. albuterol, proventil, ventolin) are the most effective class of drugs used as rescue medications.
- long term or controller medication. Inhaled corticosteroids (ICSs) (e.g. fluticasone) are the most effective class of drugs to treat the inflammation.
- long-acting B-adrenergic agonists (LABAs) are added to daily ICS. ICSs are the most effective class of drugs to treat inflammation
53
Acute asthma exacerbations:
Asthma exacerbations may be mild to life-threatening. With mild exacerbations, patients have difficulty breathing only with activity and may feel that they "can't get enough air". What are the medications
Peak flow is >70% of personal best, and symptoms often are relieved at home promptly with an SABA such as albuterol delivered by a nebulizer or metered dose inhaler (MDI) with a spacer.
54
Acute asthma exacerbations:
With a moderate exacerbation, dyspnea interferes with usual activities and peak flow is 40-60% of personal best. In this situation, the patient usually comes to the ER or an HCP's office to get help. Relief is provided with?
SABA and oral corticosteroids. Symptoms may persist for several days even after corticosteroids are started. Oxygen can be used with both mild and moderate exacerbations.
55
Severe and Life-Threatening Asthma Exacerbations:
| Management of the patient with severe and life-threatening asthma focuses on?
correcting the hypoxemia and improving ventilation. The goal is to keep the O2 saturation >/- 90%. Continuous monitoring of the patient is critical.
56
Severe and Life-Threatening Asthma Exacerbations:
Many therapeutic measures are the same as those for acute asthma. Repetitive or continuous SABA administration is provided in the emergency department (ED). Initially?
three treatments of SABA (spaced 20-30 min. apart) are given. Then more SABA is given depending on the patient's airflow, improvement, and side effects from the SABA.
57
Severe and Life-Threatening Asthma Exacerbations:
| In life-threatening asthma, what medications are given?
IV corticosteroids are administered and are usually tapered rapidly. IV corticosteroids (methylprednisolone) are administered every 4-6 hours. Adjunctive medications such as IV magnesium sulfate may be administered for bronchodilation in patients with very low forced expiratory volume at 1 minute (FEV1) or peak flow (<40% of predicted or personal best at presentation) or those who fail to respond to initial treatment.
58
Severe and Life-Threatening Asthma Exacerbations:
| Supplemental O2 is given by?
mask or nasal prongs to achieve a PaO2 of at least 60mm Hg or an O2 saturation >90%
59
Asthma: Occasionally, asthma exacerbations are life-threatening, with impending respiratory arrest. The patient requires?
intubation and mechanical ventilation if there is no response to treatment. The patient is provided with 100% oxygen, hourly or continuously nebulized SABA, IV corticosteroids, and other adjunctive therapies
60
Asthma drug therapies:
A stepwise approach to drug therapy is based initially on asthma severity and then on level of control. Persistent asthma requires daily long-term therapy in addition to appropriate medications to manage acute symptoms. Medications are divided into two general classifications
1) Quick-relief or rescue medications to treat symptoms and exacerbations, such as SABAs
2) Long-term control medications to achieve and maintain control of persistent asthma such as ICS. Some of the controllers are used in combination to gain better asthma control (e.g fluticasone/salmeterol)
61
Asthma patient teaching:
| Patient teaching about medications should include?
- Name
- Purpose
- Dosage
- Method of administration
- Schedule (taking into consideration ADLs such as bathing) that require energy expenditure and thus oxygen
- Also include side effects, appropriate actions for side effects, and how to properly use and clean devices
62
Nursing management for asthma
The patient with asthma will have minimal symptoms during the day and night, acceptable activity levels (including exercise and other physical activity), greater than 80% of personal best PEFR, few or no adverse effects of therapy, no acute exacerbations, and adequate knowledge to participate in and carry out the plan of care.
.
63
Asthma nursing diagnosis
- Ineffective airway clearance
| - Anxiety
64
Nursing interventions for asthma
| A goal in asthma care is to maximize the patient's ability to safely manage?
acute asthma exacerbations via an asthma action plan developed in conjunction with the HCP
65
Nursing interventions for asthma
The patient can take 2-4 puffs of an SABA every 20 minutes three times as a rescue plan. Depending on the response with alleviation of symptoms or improved peak flow, continued SABA use and/or oral corticosteroids may be a part of the home management plan. If symptoms persist or if the patient's peak flow is <50% of the personal best, the?
HCP or emergency medical services need to be immediately contacted
66
Nursing interventions for asthma:
| When the patient is in the health care facility with an acute exacerbation, it is important to monitor the?
Respiratory and cardiovascular systems. This includes auscultating lung sounds and monitoring heart rate and respiratory rate, BP, pulse oximetry, and peak flow
67
Nursing interventions for asthma:
| An important nursing goal during an acute attack is to decrease?
The patients sense of panic. Stay with the patient. A calm, quiet, reassuring attitude may help the patient relax. Position patient comfortably (usually sitting) to maximize chest expansion
- in a firm calm voice, coach the patient to use pursed-lip breathing, which keeps the airways open by maintaining positive pressure, and abdominal breathing, which slows the respiratory rate and encourage deeper breaths
68
Asthma Long-Term Control Medications
1) Antiinflammatory Drugs
2) Bronchodilators
1) Antiinflammatory Drugs
- Corticosteroids
• Inhaled (e.g., fluticasone [Flovent Diskus or HFA])
• Oral (e.g., prednisone)
- Leukotriene modifiers (e.g., montelukast [Singulair])
Anti-IgE (omalizumab [Xolair])
2) Bronchodilators
- Long-acting inhaled β2-adrenergic agonists (e.g., salmeterol [Serevent])
- Long-acting oral β2-adrenergic agonists (e.g., albuterol [VoSpire ER])
- Methylxanthines (e.g., theophylline [Theo-24]
69
Asthma Quick Relief Medications
1) Bronchodilators
2) Antiinflammatory Drugs
1) Bronchodilators
- Short-acting inhaled β2-adrenergic agonists (e.g., albuterol [Proventil HFA])
- Anticholinergics (inhaled) (e.g., ipratropium [Atrovent HFA])*
2) Antiinflammatory Drugs
- Corticosteroids (systemic) (e.g., prednisone)†
70
Mild
Dyspnea occurs with activity and patient may feel that he or she “can't get enough air.” PEF ≥70% of predicted or personal best
• Usually treated at home
• Prompt relief with inhaled SABA such as albuterol (delivered via a nebulizer or MDI with a spacer)
• Patients instructed to take 2 to 4 puffs albuterol every 20 min three times to gain rapid control of symptoms
• Occasionally short course of oral corticosteroids is needed.
Mild Dyspnea occurs with activity and patient may feel that he or she “can't get enough air.” PEF ≥70% of predicted or personal best
• Usually treated at home
• Prompt relief with inhaled SABA such as albuterol (delivered via a nebulizer or MDI with a spacer)
• Patients instructed to take 2 to 4 puffs albuterol every 20 min three times to gain rapid control of symptoms
• Occasionally short course of oral corticosteroids is needed.
71
COPD 6 Main points
1) Preventable and treatable
2) Chronic bronchitis w/ productive cough for 3 months in 2 consecutive years
3) Emphysema
4) Asthma
5) 3rd leading cause of death
6) Chronic airway inflammation
72
COPD Effects on respiratory tract
1) Increased production of mucus
2) Hyperplasia of goblet cells
* Increased production of mucus
3) Lost or decreased ciliary activity
4) Chronic, enhanced inflammation
73
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease characterized by?
- COPD is associated with an enhanced chronic inflammatory response in the airways and lungs, primarily caused by?
- persistent airflow limitation that is usually progressive.
- cigarette smoking and other noxious particles and gases. COPD exacerbations and other coexisting illnesses or co-morbidities contribute to the overall severity of the disease.
74
Previous definitions of COPD have included such terms as chronic bronchitis and emphysema, but neither term is part of the current definition of COPD.
1) Chronic bronchitis, the presence of?
2) Emphysema is the?
1) Chronic bronchitis, the presence of cough and sputum production for at least 3 months in each of 2 consecutive years, is an independent disease that may precede or follow the development of airflow limitation.
2) Emphysema is the destruction of the alveoli and is a pathologic term that explains only one of several structural abnormalities in COPD patients.
75
Patients with COPD may have a predominance of one of these conditions, Chronic bronchitis or emphysema, but the conditions usually?
coexist, and COPD is considered one disease state in terms of pathophysiology and management
76
Patients with COPD may have asthma. Asthma may be a risk factor for the development of COPD. There is a considerable pathologic and functional overlap between these disorders, particularly among?
older adults, who may have components of both diseases. Recently this disorder has been called asthma-COPD overlap syndrome
77
The major risk factor for developing COPD is?
- cigarette smoking
- affects about 15% of smokers
- COPD should be considered in any person who is over the age of 40 with a smoking history of 10 or more pack-years.
78
COPD:
Cigarette smoke has several direct effects on the respiratory tract.
1) The irritating effect of the smoke causes?
2) Hyperplasia reduces?
3) Smoking reduces the?
4) Many cells develop large, atypical nuclei, which are considered a precancerous condition. Smoking causes chronic, enhanced inflammation of various parts of the lung with structural changes and repair (called remodeling). The reasons for the inflammatory response are not clearly understood but may be genetically determined, since?
1) hyperplasia of cells, including goblet cells, thereby increasing the production of mucus.
2) airway diameter and increases the difficulty in clearing secretions.
3) ciliary activity and may cause actual loss of cilia. Smoking also produces abnormal dilation of the distal air space with destruction of alveolar walls.
4) patients who have never smoked can develop COPD.
79
COPD: Occupational Chemicals and Dusts.
If a person has intense or prolonged exposure to various dusts, vapors, irritants, or fumes in the workplace, symptoms of?
lung impairment consistent with COPD can develop. If a person has occupational exposure and smokes, the risk of COPD increases
80
COPD: Air Pollution.
High levels of urban air pollution are harmful to people with existing lung disease. However, the effect of outdoor air pollution as a risk factor for the development of COPD is unclear. Another risk factor for COPD development is?
coal and other biomass fuels that are used for indoor heating and cooking. Many people who have never smoked are at significant risk for developing COPD because of cooking with these fuels in poorly ventilated areas
81
Passive smoking is the exposure of?
nonsmokers to cigarette smoke, also known as environmental tobacco smoke (ETS) or secondhand smoke.
82
COPD: Infection.
Infections are a risk factor for developing COPD. Severe recurring respiratory tract infections in childhood have been associated with reduced lung function and increased respiratory symptoms in adulthood. It is unclear whether the development of COPD can be related to recurrent infections in adults. People who smoke and also have?
human immunodeficiency virus (HIV) infection have an accelerated development of COPD. Tuberculosis is also a risk factor for COPD development.
83
Occupational COPD can develop with intense or prolonged exposure to?
Dusts, vapors, irritants, or fumes
High levels of air pollution
Fumes from indoor heating or cooking with fossil fuels
84
COPD Aging
Some degree of emphysema is common because of physiologic changes of aging lung tissue.
85
Risk factors for COPD
- Smoking
- Occupational chemicals and dusts
- Air pollution
- Infection
- Genetics
- Aging
86
COPD Patho
- Exposure to noxious particles, gas or smoke
* inflammation of central airways
* inflammation of peripheral airways
* gas exchange imbalance
* pulmonary vascular changes
- hypersecetion of mucous
- cilia dysfunction
- airflow limitation
- alveolar destruction
- hyperventilation
- pulmonary hypertension
87
COPD Complications (4)
1) Cor Pulmonale- results from hypertension
2) Acute respiratory failure
3) COPD exacerbation
4) Depression and anxiety
88
COPD Diagnostic studies (4)
1) Spirometry-confirms presence of airway obstruction
2) Chest xray
3) Dyspnea scale
4) 6 minute walk test
89
COPD Description
- Airflow limitation not fully reversible
- Generally progressive
- Abnormal inflammatory response of lungs to noxious particles or gases
90
COPD Includes
- Chronic bronchitis
| - Emphysema
91
COPD Significance
- Third leading cause of death in the United States
| - Kills more than 120,000 Americans each year
92
COPD Etiology
Risk factors
1) Cigarette smoking – EVERYONE OVER THE AGE OF 40 AND A SMOKING HISTORY OF 10 OR MORE PACK/YEAR SHOULD BE CONSIDERED.
2) Occupational chemicals and dust
3) Air pollution
4) Infection
5) Heredity
6) Aging
93
COPD Cigarette Smoking
- Clinically significant airway obstruction develops in 15% of smokers
- 80% to 90% of COPD deaths are related to tobacco smoking.
94
COPD Cigarette Smoking: Effects of nicotine
1) Stimulates sympathetic nervous system
2) Increases HR
3) Causes peripheral vasoconstriction
4) Increases BP and cardiac workload
5) ↓ Amount of functional hemoglobin
6) ↑ Platelet aggregation
7) Compounds problems in CAD
95
A diagnosis of COPD should be considered in any patient who is?
over the age of 40 who has symptoms of cough, sputum production, or dyspnea, and/or a history of exposure to risk factors for the disease.
96
COPD Cigarette Smoking: Effects on respiratory tract
1) Increased production of mucus
2) Hyperplasia of goblet cells
3) Increased production of mucus
4) Lost or decreased ciliary activity
5) Chronic, enhanced inflammation
97
COPD first symptom
A chronic intermittent cough is the earliest symptom. As the disease progresses, the cough is present every day.
• Sputum may or may not be produced. Symptoms are progressive.
98
COPD: Dyspnea with exertion is often progressive. In the late stages of COPD, dyspnea may be?
present at rest. Wheezing and chest tightness may vary by time of the day or from day to day, especially in patients with more severe disease
99
COPD: The patient with advanced COPD experiences?
weight loss, even with adequate caloric intake. Fatigue is a prevalent symptom that affects activities of daily living
100
COPD: During physical examination, a prolonged expiratory phase of?
respiration, wheezes, or decreased breaths sounds are noted in all lung fields. The anterior diameter of the chest is increased (barrel chest) from chronic air trapping. The patient may assume a tripod position and use pursed lip breathing
101
COPD: over time, hypoxemia may develop with hypercapnia. The bluish red color of the skin results from?
polycythemia and cyanosis. Polycythemia develops as a result of increased production of RBCs as the body attempts to compensate for chronic hypoxemia
102
COPD can be classified as?
mild, moderate, severe, and very severe, depending on the severity of the obstruction.
103
Complications of COPD include the following:
♣ Cor pulmonale
♣ Exacerbations of COPD are signaled by a change in the patient’s?
♣ Patients with severe COPD who have exacerbations are at risk for the development of? What should you teach them?
♣ Cor pulmonale is hypertrophy of the right side of the heart, with or without heart failure, resulting from pulmonary hypertension and is a late manifestation of chronic pulmonary heart disease.
♣ usual dyspnea, cough, and/or sputum that is different than the usual daily patterns. Primary cause is bacerial or viral infection. They are typical and increase in frequency (averaging one or two a year) as disease progresses. These flares require changes in management and can have significant mortality if not appropriately treated.
♣ respiratory failure. Teach early recognition of the three cardinal symptoms of exacerbations (increase in dyspnea, sputum volume, or sputum purulence) to promote early treatment and thus prevent hospitalization and possible respiratory failure
104
COPD: Other complaints include?
| -Exacerbations are managed with?
Malaise, insomnia, increased wheezing, fatigue, depression, confusion, and decreased exercise tolerance.
- managed with short acting bronchodilators, oral systemic corticosteroids, and antibiotics
105
COPD: Acute respiratory failure may occur in patients with severe COPD who have exacerbations. Be alert for signs of increasing severity such as?
use of accessory muscles, central cyanosis, edema in the lower extremities, unstable BP, right-sided heart failure, and altered alertness. Frequently, patients with COPD with too long to contact an HCP after first experiencing symptoms suggesting an exacerbation. Discontinuing bronchodilator or corticosteroid medication may also precipitate respiratory failure.
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COPD: Diagnostic studies
1) A forced expiratory volume in 1 minute/forced vital capacity ratio (FEV1/FVC) less than 70% along with the appropriate symptoms can help to diagnose COPD. A lower value of FEV1 indicates more severe COPD
2) History/physical exam
3) Chest x-ray NOT diagnostic but may show a flat diaphragm due to hyperinflation of lungs
4) ECG can be used to determine right and left sided ventricular failure
5) Sputum culture and sensitivity are done if an acute exacerbation is present
6) Arterial blood gases (ABGs) in later stages usually indicate low PaO2, elevated PaCO2, decreased or low normal pH, and increased bicarbonate (HCO3)
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The diagnosis of COPD is confirmed by?
spirometry
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COPD Diagnosis
The diagnosis of COPD is confirmed by spirometry.
♣ Goals of the diagnostic workup are to?
♣ A diagnosis of COPD is made?
♣ Other evaluations may be used to assess the patient as outlined by the Global Initiative for COPD (GOLD), which lay the groundwork for management of COPD. Assessment of a patient may include?
♣ (1) confirm the diagnosis of COPD via spirometry and (2) determine the impact of the disease on the patient’s quality of life.
♣ the FEV1/FVC ratio is less than 70% and related symptoms are present.
♣ level of symptoms (using COPD Assessment Test [CAT]), severity of disease (FEV1), exacerbation risk, and presence of co-morbidities
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COPD Interprofessional care
Most patients with COPD are treated as outpatients. They are hospitalized for complications such as acute exacerbations and acute respiratory failure.
-Evaluate the patients exposure to environmental or occupational irritants, and determine ways to control or avoid them. The patient with COPD and anyone who smokes should receive an?
influenza immunization yearly. The pneumococcal vaccine is recommended for smokers 19 yrs of age or older and patients with COPD
110
The primary goals of care for the COPD patient are to?
prevent disease progression, relieve symptoms and improve exercise tolerance, prevent and treat complications, promote patient participation in care, prevent and treat exacerbations, and improve quality of life and reduce mortality.
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Cessation of cigarette smoking in all stages of COPD is the intervention that can have the?
biggest impact to reduce the risk of developing COPD and influence the natural history of the disease.
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Medications for COPD can?
Reduce symptoms, increase exercise capacity, improve overall health, and reduce the number and severity of exacerbations
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Although patients with COPD do not respond as dramatically as those with asthma to bronchodilator therapy, bronchodilator therapy can reduce the?
dyspnea and increase the FEV1.
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COPD Medications: Bronchodilator medications commonly used are B2-adrenergic agonists, anticholinergic agents, and methylxanthines.
1) When the patient has mild COPD or intermittent symptoms, a?
2) In the moderate stage of COPD, a?
1) short acting bronchodilator is used as needed.
| 2) long-acting bronchodilator also is used
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In patients with COPD associated with an FEV1 less than 60%, regular treatment with?
inhaled corticosteroids (ICSs) is often prescribed, in addition to a long-acting B-agonist (LABA).
116
COPD: Inhaled anticholinergics or long-acting β2 agonists may be used or combined with?
inhaled corticosteroids.
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COPD: Monotherapy with inhaled corticosteroids is not recommended due to the?
side effects.
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COPD: Long term continuous (more than 15 hr/day) O2 therapy (LTOT) increases survivial and improves exercise capacity and mental status in hypoxemic patients with COPD
.
119
COPD: The main types of breathing exercises commonly taught are?
pursed-lip breathing and diaphragmatic breathing. However, patients with moderate to severe COPD with marked hyperinflation may be poor candidates for diaphragmatic breathing
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Four different surgical procedures have been used in severe COPD.
♣ Lung volume reduction surgery is used to reduce the?
♣ Bronchoscopic lung volume reduction surgery works by placing?
♣ A bullectomy is used for certain patients and can result in?
♣ Lung transplantation can improve functional capacity and enhance quality of life in appropriately selected patients with?
♣ size of the lungs by removing the most diseased lung tissue so that the remaining healthy lung tissue can perform better.
♣ one-way valves in the airways leading to the diseased parts of the lung. The valves let air out but not in. This collapses a certain segment of the lung and has a similar result as LVRS.
♣ improved lung function and reduction in dyspnea.
♣ very advanced COPD.
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Breathing retraining such as pursed-lip breathing is a technique that is used to?
prolong exhalation and thereby prevent bronchiolar collapse and air trapping.
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Airway clearance techniques include effective?
coughing techniques, chest physiotherapy, and airway clearance devices. No one is better than the other, but it depends on patient preference.
123
Airway clearance techniques do what?
Loosen mucus and secretions for clearance by coughing. A variety of treatments can be used to achieve airway clearance. Respiratory therapists, physical therapists, and nurses are involved in performing these techniques
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Airway clearance techniques:
♣ Effective coughing conserves energy, reduces fatigue, and facilitates removal of secretions. Huff coughing is an?
♣ Chest physiotherapy consists of?
♣ Airway clearance devices include those using?
♣ effective technique that the patient can be easily taught.
♣ percussion, vibration, and postural drainage.
♣ positive airway pressure, such as Flutter, Acapella, or TheraPEP. High frequency chest wall oscillation, such as SmartVest, helps to clear airways.
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COPD: Weight loss and malnutrition are commonly seen in the patient with severe emphysematous COPD. The patient with weight loss needs?
extra protein and calories, moderate in carbs and moderate to high in fat and tips on energy conservation while eating and preparing food.
- To decrease dyspnea and conserve energy, the patient should rest at least 30 minutes before eating a meal and use a bronchodilator before meals
- they should consume five or six small meals a day
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COPD NURSING MANAGEMENT
• The patient with COPD will require acute care for complications such as exacerbations of?
• Pulmonary rehabilitation should be considered for all patients with COPD or having functional limitations. The overall goal is to?
• Walking is an?
* COPD, pneumonia, cor pulmonale, and acute respiratory failure.
* increase the quality of life and improve exercise capacity.
* inexpensive, effective exercise for the COPD patient. Also, adequate sleep is extremely important.
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COPD Nursing diagnosis
- Ineffective airway clearance
- Ineffective breathing pattern
- Imparied gas exchange
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COPD: O2 therapy is frequently used in the treatment of COPD and other problems associated with hypoxemia. Long-term O2 therapy (>15 hr/day) improves?
survival, exercise capacity, cognitive performance, and sleep in hypoxemic patients.
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COPD: Goals for O2 therapy are to reduce the work of?
breathing, maintain the PaO2, and/or reduce the workload on the heart, keeping the SaO2 more than 90% during rest, sleep, and exertion, or PaO2 more than 60 mm Hg.
130
COPD: O2 delivery systems are classified as low- or high-flow systems. Most methods of O2 administration are?
low-flow devices that deliver O2 in concentrations that vary with the person’s respiratory pattern.
131
COPD: Dry O2 has an irritating effect on mucous membranes and dries secretions. Therefore it is important that O2 be?
humidified when administered, either by humidification or nebulization.
132
COPD: Medical complications associated with O2 therapy include?
CO2 narcosis, O2 toxicity, and infection. The risk of combustion-related injury is also a possibility requiring specific precautions for patient safety.
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COPD: Walking or other endurance exercises combined with strength training are the best interventions to strengthen muscles and improve the patients endurance. Teach the patient coordinated walking with slow, pursed lip breathing. Encourage the patient to walk?
15-20 minutes/day at least three times a week, with gradual increases
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COPDCigarette Smoking
- Carbon monoxide
↓ O2 carrying capacity
↑ Heart rate
Impaired psychomotor performance and judgment
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COPD: Passive smoking (secondhand smoke)
↓ Pulmonary function
↑ Risk of lung cancer
↑ Respiratory symptoms
136
COPD Infection
Recurring infections impair normal defense mechanisms
HIV
Tuberculosis
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COPD Heredity
-Antitrypsin (AAT) deficiency
Genetic risk factor for COPD
Accounts for 3% of COPD
AAT is an autosomal recessive disorder.
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COPD Pathophysiology
- Defining features
* Irreversible airflow limitations during forced exhalation due to loss of elastic recoil
* Airflow obstruction due to mucous hypersecretion, mucosal edema, and bronchospasm
* Supporting structures of lungs are destroyed.
* Air goes in easily, but remains in the lungs.
* Bronchioles tend to collapse.
* Causes barrel-chest look
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COPD Common characteristics
Mucus hypersecretion
Dysfunction of cilia
Hyperinflation of lungs
Gas exchange abnormalities
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COPD Clinical Manifestations
- Develops slowly
- Diagnosis is considered with
1) Cough
2) Sputum production
3) Dyspnea
4) Exposure to risk factors
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COPD: Dyspnea usually prompts medical attention.
Occurs with exertion in early stages
| Present at rest with advanced disease
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COPD: Causes chest breathing
Use of accessory and intercostal muscles
Inefficient breathing
May experience chest tightness with activity
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COPD: Physical examination findings
```
Prolonged expiratory phase
Wheezes
Decreased breath sounds
↑ Anterior-posterior diameter (barrel chest)
Tripod position
Pursed lip breathing
```
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COPD: Bluish-red color of skin
Bluish-red color of skin
| Polycythemia and cyanosis
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COPD Complications
```
Cor pulmonale
Exacerbations of COPD
Acute respiratory failure
Peptic ulcer disease
Depression/anxiety
```
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COPD Cor Pulmonale
Hypertrophy of right side of heart
Result of pulmonary hypertension
Late manifestation of chronic pulmonary heart disease
Eventually causes right-sided heart failure
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COPD Cor Pulmonale manifestations
```
Dyspnea
Distended neck veins
Hepatomegaly with right upper quadrant tenderness
Peripheral edema
Weight gain
```
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COPD Cor Pulmonale Diagnostic studies
```
ECG
Chest x-ray
Right-sided cardiac catheterization
Echocardiogram
BNP levels
```
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COPD Exacerbations
- Associated with poorer outcomes
- Primary causes
- Signs of severity
- Primary causes
* Bacterial and viral infections
- Signs of severity
* Use of accessory muscles
* Central cyanosis
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COPD Exacerbations Treatment
Short-acting bronchodilators
Corticosteroids
Antibiotics - controversial
Supplemental oxygen therapy - what is wrong with giving them too much oxygen?
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COPD Depression and Anxiety
- COPD patients experience many losses.
- If patient becomes anxious because of dyspnea, teach pursed lip breathing.
- Ask the patient if they feel down or sad most of the time.
- Medications can be prescribed for anxiety or depression
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COPD Diagnostic Studies
```
Diagnosis confirmed by spirometry
Reduced FEV1/FVC ratio
Increased residual volume
Chest x-ray
History and physical examination are also important in the diagnostic workup.
6-minute walk test to determine O2 desaturation in the blood with exercise
BODE index
ABG
```
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COPD: ABG typical findings in later stages
Low PaO2
↑ PaCO2
↓ pH
↑ Bicarbonate level found in late stages of COPD
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COPD: Bronchodilators
```
Relax smooth muscle in the airway
Improve ventilation of the lungs
↓ Dyspnea and ↑ FEV1
Inhaled route is preferred.
- Commonly used bronchodilators
β2-Adrenergic agonists
Anticholinergics
Methylxanthines
```
155
COPD:
Long-acting anticholinergic
Inhaled corticosteroid therapy
- Long-acting anticholinergic
Tiotropium (Spiriva)
- Inhaled corticosteroid therapy
Used for moderate to severe cases
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COPD:
| O2 therapy is used to
Keep O2 saturation > 90% during rest, sleep, and exertion, or
PaO2 greater than 60 mm Hg.
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COPD: Low flow delivery device
Nasal cannula
Simple face mask
Partial and non rebreathing masks
Oxygen conserving cannula
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COPD: High flow delivery device
Tracheostomy collar
| Venturi mask
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COPD: O2 delivery systems are high or low flow
- Low flow is most common
- Low flow is mixed with room air, and delivery is less precise than high flow
- High flow fixed concentration
Venturi mask
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COPD: Humidification
Used because O2 has a drying effect on the mucosa
| Supplied by nebulizers, vapotherm, and bubble-through humidifiers
161
COPD: Complications of oxygen therapy
```
Combustion
CO2 narcosis
O2 toxicity
Absorption atelectasis
Infection
```
162
COPD: Nutritional therapy
| Avoid
Foods that require a great deal of chewing
Exercises and treatments 1 hour before and after eating
Gas-forming foods
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COPD: Nutritional therapy
High-calorie, high-protein diet is recommended.
| Fluids (intake of 3 L/day) should be taken between meals.
164
The nurse reviews the arterial blood gases of a patient. Which result would indicate the patient has later stage COPD?
pH 7.32, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L
pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3 18 mEq/L
pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3 25 mEq/L
pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 35 mEq/L
pH 7.32, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L
