COPD and Pneumonia Flashcards
What is the pack year life calculation?
- number of packs smoked/ day X amount of years smokes
what are risk factors for COPD?
- smoking
- increased with number of pack years, 40 pack year strong indicator
- fumes
- organic/ inorganic dusts
- heredity
- aging
- lung infections
What is the most important risk factor for developing COPD?
smoking
What are early signs of COPD?
- morning cough
- increased production of mucous/ sputum
- breathlessness with exertion
What are not early signs of COPD?
- chest pain
- hemoptysis
- barrel chest
what test provides the best indication that a client is experiencing a persistent airflow limitation?
pulmonary function tests including FEV1/ FVC
What do pulmonary function tests do?
- determine how well lungs work
- measure
- lung volume
- capacities
- rate of flow
- gas exchange
when testing for COPD respiratory therapists start by administering what? What does this do?
- administer bronchodilator
- gets rid of any reversible airflow restriction (asthma)
Healthy peoples FEV1/FVC should be what?
80% or more out of lungs in first second
a pulmonary function test calculates 2 values what are they? describe them
- FEV1
- forced expiratory volume in 1 second
- total amount of air forcefully blown out of lungs in first second of exhalation - FVC
- forced vital capacity
- total amount of air forcefully blown out of lungs after deep breath
How is someone diagnosed with COPD using pulmonary function tests?
- decreased FVC and FEV1
- hard time getting air out of lungs
- longer FEV1 decreases even more than FVC (ration <70% someone is diagnosed)
What are some reasons for people with COPD having difficulty exhaling?
- decreased elasticity of lungs (hard to push air out)
- blocked air flow due to increased mucous production/ inflammation in airways
- barrel chest
describe restrictive lng disease
- person has trouble getting air IN lungs
- lungs restricted from expanding fully
What are some examples of restrictive lung disease?
- large pleural effusion
- neuromuscular disease (ALS)
- ascites
What is ascites?
fluid in abdomen prevents lungs from expanding
describe chronic bronchitis
- type of COPD
- characterized by productive cough for 3+ months in each of 2 successive years
- mainly affects small airways
- refers to inflammation of the bronchi
describe inflammation of bronchi in regards to chronic bronchitis
- inflammation irritates airways
- causes production of thick, sticky mucous that can block airways
- causes swelling in airways narrows space > makes more difficult for air to pass
describe emphysema
- type of COPD
- characterized by permanent enlargement of airspaces with destruction of airspace walls
- affects alveoli in lungs
describe how alveoli are affected by emphysema
- alveoli become damaged
- individual alveoli merge together
- causes one large air sac with less surface area for gas exchange
- large air sacs less elastic don’t want to shrink back to normal shape
- start acting like pillow cases > hard to get air out of lungs
some large emphysematous air sacs are what? What can happen?
- are weak and easy to tear
- can cause air to leak into pleural space causing pneumothorax
describe COPD
- respiratory disorder mainly caused by smoking
- progressive
- non-reversible
- cannot be cured
- leads to structural changes in lungs and chest
- causes reduced airflow/ collapse of small airways
describe asthma
- not a type of COPD
- airways are twitchy (hyper-responsive)
- caused by inflammation
- key features > episodic, reversible with treatment
what are characteristics of asthma
- airway inflammation with recurrent episodes of wheezing
- breathlessness
- chest tightness
- coughing
what can trigger asthma?
- allergens
- exercise
- infections
- cold/ dry air
- many other things
what are common manifestations of COPD?
- easily fatigued after exercise
- frequent respiratory infections
- chronic cough
- easily dyspneic
- producing excessive sputum
- use of accessory muscles to breathe
- orthopneic
- thin in appearance
- wheezing
- pursed-lip breathing
- barrel chest
- prolonged expiratory time
- increased sputum
- digital clubbing
- cor pulmonale
describe the stepwise management approach
- quit smoking
- COPD becomes worse
- short-acting bronchodilators PRN
- lung function worsens longer-acting bronchodilators prescribed - ADLs affected people referred to pulmonary rehabilitation program
- lung function continues to worsen
- inhaled corticosteroids (often combined with long-acting bronchodilator) prescribed - O2 levels decrease to hypoxemia > patient receives home oxygen therapy
- COPD progresses, no other treatment, becomes life threatening
- lung reduction surgery considered
describe medical research council dyspnea scale, what does each level mean?
graded 1(best) - 5 (worst)
1 – not troubled by breathlessness, except with strenuous exercise
2 – troubled by shortness of breath when hurrying on the level or walking up a slight hill
3 – walk slower than people of the same age on the level b/c of breathlessness or has to stop for breath when walking at own pace on the level
4 – stops for breath after walking about 100 yards (90m) or after a few minutes on the level
5 – too breathless to leave the house, or breathless when dressing or undressing
What are some activities for COPD patients?
- walking (best exercise)
- stretching
- strength training
- aerobic fitness
describe walking in regards to COPD patients
- low impact
- doesn’t require special equipment
- appropriate for mild-severe disease
- initially aim to walk 15-20mins/ day
- if not manageable start with slower pace, walk 2-5mins 3X/day
- as strength/ endurance increases so should duration
What are some goals for commonly prescribed medications for COPD?
- reduce symptoms
- reduce frequency/ severity of exacerbations
- improve exercise tolerance
- improve health
- no evidence that meds reduce long-term decline in persons’ lung function
What are the 6 general categories of COPD medications?
- beta adrenergic bronchodilators
- anticholinergic or anti-muscarinic bronchodilators
- inhaled corticosteroids
- oral or parental corticosteroids
- methylxanthines
- anti-inflammatories
in regards to the 6 general categories of COPD medications, describe beta adrenergic bronchodilators
- mainstays
- work on the sympathetic nervous system > dilate airways
- best supported to be beneficial with fewest side effects
- genetic names often end in -ol
what are the side effects of beta adrenergic bronchodilators ?
- making people feel shaky
- cause rapid HR
- anxiety (due to adrenergic effects)
in regards to beta adrenergic bronchodilators describe beta2 adrenergic agonists
- relax/ dilate airways
- short acting beta-adrenergic agonists (SABAs)
- long acting beta-adrenergic agonists (LABAs)
in regards to the 6 general categories of COPD medications, describe anticholinergic or anti-muscarinic bronchodilators
- mainstay
- work on the parasympathetic system
- best supported by evidence to be beneficial with fewest side effects
- relax/ dilate airways
- short acting muscarinic antagonists (SAMAs)
- long acting muscarinic antagonists (LAMAs)
in regards to anticholinergic or anti-muscarinic bronchodilators what do their genetic names end in? provide examples
end in -tropium and -ium
ex.
- ipratropium
- tiotroprium
- umeclidinium
in regards to the 6 general categories of COPD medications, describe inhaled corticosteroids
- mainstay
- best supported by evidence to be beneficial with fewest side effects
- act locally to reduce inflammation
- decrease acute exacerbations of COPD
- mainly act on the respiratory tract
- combination inhaler therapy
what are some common examples of inhaled corticosteroids?
- budesonide
- fluticasone
in regards to inhaled corticosteroids what do their generic names end in? provide examples
end in -one
ex.
- fluticasone
- mometasone
in regards to inhaled corticosteroids what side effects can they have on the respiratory tract
- suppress immune response > increase risk for opportunistic infections
- cause development of yeast or candida infection in mouth
in regards to inhaled corticosteroids describe combination inhaler therapy
- combines 2-3 drugs together
- 3 common examples
1. advair
2. anoro
3. trelegy
in regards to inhaled corticosteroids describe the first common combination inhaler
Advair
- contains long acting beta-adrenergic agonist
- salmeterol
- inhaled corticosteroid fluticasone
in regards to inhaled corticosteroids describe the second common combination inhaler
Anoro
- contains long acting beta-adrenergic agonist
- vilanterol
- long acting muscarinic antagonist
- umeclidinium
in regards to inhaled corticosteroids describe the third common combination inhaler
Trelegy
- contains long acting beta-adrenergic agonist
- vilanterol
- long acting muscarinic-antagonist
- umeclidinium
- inhaled corticosteroid fluticasone
in regards to the 6 general categories of COPD medications, describe oral or parental corticosteroids
- avoid when possible, can have serious side effects especially when taken for long time
- helpful when someone developed AECOPD
- generic names end in -one
what are some examples of generic oral or parental corticosteroids?
- prednisone
- cortisone
- dexamethasone
in regards to the 6 general categories of COPD medications, describe methylxanthines
- serious potential side effects
- not most effective treatment
- only used when COPD doesn’t respond well to other treatments
- used more commonly in developing countries that have fewer resources
describe phosphodiesterase (PDE -4 inhibitor)
- another class of medication used to manage COPD
ex. roflumilast
in regards to phosphodiesterase (PDE -4 inhibitor) describe roflumilast
- pill
- reduces inflammation/ relaxes smooth muscle in airways
- used to prevent AECOPD with frequent exacerbations
in regards to phosphodiesterase (PDE -4 inhibitor), what can roflumilast cause?
- weight loss
- worrisome for people who might be underweight already due to lung disease - GI upset
- nausea
- diarrhea
acute exacerbation of COPD is considered to be what?
a sustained change (48hrs+) in dyspnea, cough, sputum, production that requires person to use more medication to manage symptoms
what should people with COPD get immunized against?
- influenza
- pneumococcus
What is pneumococcus?
bacteria that can cause pneumonia, sinus infections, ear infections, meningitis and sepsis
What is the most common cause of AECOPD?
respiratory infections
what are clinical manifestations of community-acquired pneumonia?
- Fever and chills
- Cough
- Dyspnea
- Pleuritic chest pain
- Tachypnea
- Increased work of breathing
- Adventitious lung sounds (course or fine crackles)
- Mental status changes (especially in older adults)
what are symptoms for bacterial community acquired pneumonia
- More severe exacerbation of COPD
- Increased production of sputum
- Purulent sputum
What is the difference between purulent and non-purulent AECOPD?
purulent
- Sputum contains pus
- Looks thick yellow or green
- Suggests bacterial infection
- Antibiotics recommended even if person hasn’t gotten a culture/ sensitivity test
non-purulent
- less dyspnea
- sputum without pus
- viral infection
what is empirical therapy for pneumonia?
- Therapy based on healthcare providers observations/ experience when the actual causative organisms is not known
- educated guess
- Often given with antibiotics too
what is community acquired pneumonia?
- developing outside hospital
- having COPD greatest risk for hospitalization
What lab values should be looked at specifically in regards to COPD?
- hemoglobin
- hematocrit
- C-reactive protein
what does an elevated Hemoglobin lab value tell us about COPD?
- one of the ways body compensates for chronically low oxygen levels
- also called polycythemia
what does a hematocrit lab value tell us about COPD?
- ratio of RBCs compared to amount of fluid or plasma in blood
- elevated > more RBCs compared to plasma amount
what does a C-reactive protein lab value tell us about COPD?
when elevated means:
- acute phase reactant
- infection or inflammatory process somewhere in body
care plan for AECOPD and pneumonia includes what?
- encourage rest
- frequent turning and re-positioning
- encouraging ambulation
- incentive spirometry/ deep breathing and coughing exercises
- increasing fluid intake
in regards to a care plan for AECOPD and pneumonia what does encourage rest do?
reduce body demand for oxygen
in regards to a care plan for AECOPD and pneumonia what frequent turning and re-positioning do?
- prevent skin breakdown
- help improve drainage of secretions in lungs
in regards to a care plan for AECOPD and pneumonia what does encouraging ambulation do?
prevents:
- complications of immobility
- skin breakdown
- muscle de-conditioning
- blood clots
in regards to a care plan for AECOPD and pneumonia what does incentive spirometry/ breathing and coughing exercises do?
- improve lung expansion
- mobilize lung secretions
in regards to a care plan for AECOPD and pneumonia what does increasing fluid intake do?
- keep lung secretions thin and easy to cough up
What are other interventions for AECOPD and pneumonia?
- Administering oral nutritional supplements
- Administering SABAs via nebulizer or metred-dose inhaler
- Administering SAMAs with SABAs in combination
- Reviewing inhaler technique
- Administering ordered antibiotics
describe oxygen saturation and COPD
- level depends on how bad COPD is
- always look at patients normal baseline, and aim to get back to that
What are the different ranges for oxygen saturation in regards to the severity of COPD
- mild
- may have normal O2STAT
- 95+ - moderate
- normally have slight decreased O2STAT
- lower 90% range - severe
- baseline O2STAT
- 80-90%
When do you administer supplemental 02 for COPD patients?
if patients appears:
- hypoxemic
- tachycardia
- decreased O2 STAT
- shows increased work of breathing
- gets overly anxious
define hypoxic drive
when oxygen levels decrease, it stimulates increased ventilation
describe hypoxic drive
- chemoreceptors detect CO2 and O2 levels > control ventilation
- affects blood pH
- CO2 and pH levels have stronger influence on breathing than O2
define hypercapnia
- elevated CO2
- stimulates body to increase ventilation
describe hypercapnia and advanced COPD
more advanced COPD tent to chronically have higher than normal levels of CO2 in bloodstream
in regards to hypoxic drive what can happen over time ?
- CO2 receptors in body become less sensitive to elevated levels
- people with advanced COPD need to rely on O2 receptors t control ventilation
describe long term oxygen therapy in regards to COPD
- prescribed when people have severe resting hypoxemia
- Might also be recommended for people with COPD who are unable to tolerate exercise
What are the 2 situations best supported by evidence for a person with COPD to receive home oxygen therapy?
- Monitor a person’s arterial blood gases > find their partial pressure of oxygen is consistently < 55mmHg
- Monitor person’s oxygen saturation levels and find it’s consistently < 88%
Why is oxygen therapy recommended for people with COPD who are unable to tolerate exercise?
- Oxygen only worn during exertion to improve dyspnea and the person’s tolerance for exercise
- could help improve overall health/ quality of life
What are signs of potential respiratory failure?
- change in mental status
- tachycardia
- hypertension
- tachypnea
- worsening dyspnea
- severe morning headache
What is the first sign of potential respiratory failure and why?
- change in mental status
- brain is really sensitive to low O2 levels
what are common non-invasive ventilation (NIV) devices used to administer medication? What do they involve?
- optiflow
- airvo
- BiPAP
- all devices involve aerosol-generating medical procedures
What does non-invasive ventilation not require? What does this lead to?
- doesn’t require endotracheal intubation
- leads to lower risk of complications than a traditional mechanical ventilator
describe non-invasive ventilation (NIV)
- helps support person’s breathing when they’re still able to breath a bit on their own
- improve oxygenation
- Reduces person’s work to breath/ improves gas exchange in lungs
- reduces length of person’s hospital stay/ improves survival rates
how is non-invasive ventilation (NIV) administered?
face mask or nasal mask
what are bullae?
large air spaces in the parenchyma
What are blebs?
air spaces adjacent to pleurae
are bullae and blebs effective in gas exchange?
no b/c capillary bed that normally surrounds each alveolus doesn’t exist in either
What do bullae and blebs lead to?
- significant ventilation perfusion mismatch
- hypoxemia
why do people with COPD develop pulmonary hypertension?
- occurs in later stages of COPD
- Small pulmonary arteries undergo vasoconstriction resulting in thickening of vascular smooth muscle as disease advances
- Due to loss of the alveolar walls and capillaries surrounding them pressure in pulmonary circulation increases
how do the clinical manifestations of COPD differ from those of asthma?
COPD
- > 40yrs
- > 10 packs/year
- clinical symptoms persistent
- sputum production
- infrequent allergies
- spirometry findings may improve but never normalize
- progressive worsening with exacerbations
Asthma
- <40yrs
- can be triggered from history
- intermittent/ variable clinical symptoms
- infrequent sputum production
- allergies
- spirometry findings normalize
- stable with exacerbations
What is the forced vital capacity (FVC) test used for in COPD?
Amount of air that can be quickly and forcefully exhaled after maximum inspiration
what is the forced expiratory volume in the first second of expiration (FEV1) test used for in COPD?
- Amount of air exhaled in the first second of FVC
- valuable clue to severity of airway obstruction
What is the FEV1/ FVC test used for in COPD?
- Ratio of value for FEV1 to value for FVC
- useful in differentiating obstructive and restrictive pulmonary dysfunction
what is the peak expiratory flow rate (PEFR) test used for in COPD?
- Maximum airflow rate during forced expiration
- aids in monitoring bronchoconstriction in asthma
how are acute exacerbations of COPD (AECOPD) defined?
Sustained worsening of dyspnea, cough or sputum production that leads to increased use of maintenance medications or supplementation with additional medications
sustained > change from baseline that lasts 48+ hrs
Why is it important to identify whether a client has a purulent or nonpurulent exacerbation of COPD?
- Purulent exacerbations need to be treated with antibiotic therapy
- often given 7-10 day antibiotic therapy
if someone has a purulent exacerbation of COPD what antibiotics can they be put on?
- amoxicillin
- cefuroxime
- cefixime
- azithromycin
- clarithromycin, trimethoprimsulphamethoxazole
- doxycycline
- moxifloxacin
- levofloxacin
What medications (commonly used to treat disorders in older adults) can worsen COPD symptoms?
- Nonspecific beta blockers
- can block alpha 2 receptors in the airway
- cause bronchoconstriction - Angiotensin-converting enzyme inhibitors
- cause a dry cough or worsen a current cough
What physical characteristics of older adults can make management of COPD difficult?
- Cognitive impairment
- Arthritis in the hands
- Poor memory
- Visual impairment
describe community-acquired pneumonia
- Lower respiratory infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization
- Highest in the winter months
- Causative organism in CAP identified only 50% of the time
What organisms commonly implicate in community acquired pneumonia?
- S. pneumoniae
- Atypical organisms
- Legionella
- Mycoplasma
- Chlamydia
- Viral
describe hospital-acquired pneumonia
- occurring +48hrs after hospital admission
- not incubating at the time of hospitalization
- Accounts for 25% of all intensive care unit infections
What organisms commonly implicate in hospital acquired pneumonia?
- Pseudomonas
- Enterobacter
- S. aureus
- Methicillin resistant staphylococcus aureus (MRSA)
- S. pneumoniae
What are the 4 stages of the disease process in pneumonia?
- congestion
- red hepatization
- grey hepatization
- resolution
in regards to the 4 stages of the disease process in pneumonia, describe congestion
- After the pneumococcus organisms reach the alveoli via droplets or saliva, there is an outpouring of fluid into the alveoli
- Organisms multiply in the serous fluid and infection is spread
- Pneumococci damage the host by their overwhelming growth and interference with lung function
in regards to the 4 stages of the disease process in pneumonia, describe red hepatization
- Massive dilation of the capillaries, and alveoli are filled with organisms, neutrophils, RBCs and fibrin
- Lung appears red and granular (similar to liver)
in regards to the 4 stages of the disease process in pneumonia, describe grey hepatization
- blood flow decreases
- leukocytes and fibrin consolidate in affected part of lung
in regards to the 4 stages of the disease process in pneumonia, describe resolution
- Complete resolution and healing occur if there are no complications
- Exudate becomes lysed and is processed by the macrophages
- Normal lung tissue is restored, person’s gas-exchange ability returns to normal
What are the complications of pneumonia?
- pleurisy
- pleural effusion
- atelectasis
- delayed resolution
- lung abscess
- empyema
- pericarditis
- bacteremia
- meningitis
- endocarditis
What types of pneumonia respond best to antibiotic therapy?
- community acquired pneumonia
- bacterial and mycoplasma pneumonia
