Obstructive Pulmonary Diseases Flashcards
Asthma - incidence
- 38% higher in blacks than whites
- Hispanics, especially from Puerto Rico have higher rates of asthma and age-adjusted death rates than all other racial and ethnic groups
- Black females have the highest mortality rates from asthma
Heterogeneous disease characterized by a combination of bronchial hyperresponsiveness with reversible expiratory airflow limitation - Signs and symptoms may vary
- Clinical course can be unpredictable
Significance and gender differences with asthma
1.7 million ED visits/year
Incidence increasing but mortality decreasing
Gender differences
- More men affected before puberty; more women in adulthood
- Women more likely to be hospitalized
- Higher mortality in women
Risk factors of asthma
- History of allergic rhinitis common
- Acute and chronic sinusitis might make asthma worse
- Major precipitating factor of an acute asthma attack
– Acute infection—reduced airway diameter and increased airway hyperresponsiveness
– Viral-induced changes may exacerbate asthma
Common triggers of asthma
- Cigarette Smoke
- Air Pollutants
- Occupational Factors
- Exercise
- Drugs and Food Additives
- GERD
- Genetics
- Role in development of asthma unclear
- Cockroaches
– Animal dander
– Dust mites
– Fungi
– Pollen
– Molds
Manifestations of asthma
- Characteristic manifestations: wheezing, cough, dyspnea, and chest tightness
– Hyperinflation and prolonged expiration due to air trapping in narrowed airways - Wheezing—unreliable to gauge severity of attack (must move air to make the sound)
– Mild attack—may have loud wheezing
– Severe attack—wheezing with forced expiration or no wheezing at all - Decreased or absent breath sounds may occur with exhaustion or inability to have enough muscle force for breathing
– “Silent chest”—ominous sign
– Severe airway obstruction or impending respiratory failure; may be life-threatening
Acute asthma attack signs
Acute attack—wheezing is most common
- Initially expiration, then with progression, both inspiration and expiration
Manifestations of asthma: hyperventilation and alveolar perfusion
Hyperventilation—increased lung volume from trapped air and limited airflow
Abnormal alveolar perfusion and ventilation
- Hypoxemic, decreased PaCO2, increased pH
- Respiratory alkalosis results in respiratory acidosis as patient tires; sign of respiratory failure
Cough variant asthma
- Cough is only symptom
- Bronchospasm is not severe enough to cause airflow obstruction
- May be nonproductive or productive with thick, tenacious secretions
Asthma classifications
Classifications
- Intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
Impairment criteria:
- Frequency of symptoms
- Nighttime awakenings
- SABA use for symptoms
- Interference with normal activity
- Lung function: FEV1,FVC
Risk of exacerbation
Severity is used to guide treatment decisions initially, then addresses level of control
All patients should have an asthma action plan for acute attacks and to prevent future attacks
Patient education and adherence is emphasized
Complications of asthma: asthma attacks
Asthma attacks are variable and unpredictable
- Mild to life-threatening
- Last few minutes to hours
- Between attacks, often asymptomatic
- Compromised pulmonary function to debilitation
- Complications may include: pneumonia, tension pneumothorax, status asthmaticus or acute respiratory failure
Complications of asthma: status asthmaticus
Extreme acute asthma attack characterized by hypoxia, hypercapnia, and acute respiratory failure; life-threatening
emergency - need intubation, sedation, IV magnesium sulfate
Diagnostic studies for asthma
- Detailed history and physical exam
- Peak expiratory flow rate (PEFR)
- Peak flow meter
– Predict attack or monitor severity - Spirometry—lung volumes and capacities
– Stop bronchodilators 6 to 12 hours prior
– Reversibility of obstruction following bronchodilator is important for diagnosis - Fraction of exhaled nitric oxide (FENO)
– Increased levels with eosinophilic-induced inflammation - Serum eosinophils and IgE—increased levels with atopy
- Allergy testing
- Oximetry; ABGs
- Chest x-ray—rule out other disorders
- Sputum culture and sensitivity
– Rule out bacterial infection
Goal of treatment for asthma
to achieve and maintain control; return to best possible level of daily functioning
Medication guidelines based on steps
- Symptoms worse—step up medications
- Symptoms controlled—step down medications
Mild-moderate attack symptoms of asthma
- No more than 2x/week
- Minimal interference in ADLs
- Alert, oriented, speaks in sentences
- May have some chest tightness and dyspnea
- Increased use of asthma meds
- O2 saturation > 90% on room air
- PEFR > 50% predicted or personal best
Mild-moderate attack of asthma: treatment
- *Inhaled bronchodilators and oral corticosteroids
- Monitor VS
- Monitor as outpatient unless not responding to treatment or another contributing factor
- Follow-up with HCP
Severe asthma attack symptoms
- Alert and oriented but focused on breathing
– Frightened; agitated if hypoxemic - Tachycardia, tachypnea (>30 breaths/min)
- Accessory muscle use; sits forward
- Wheezing
- PEFR < 50% predicted or personal best
- Recurring symptoms interfere with ADLs
Severe asthma attack treatment
- ED -> hospital admission
- Supplemental O2 and oximetry
– PaO2 > 60 mmHg or SaO2 > 93% - Monitor PEFR, ABGs, VS
- Bronchodilators and oral corticosteroids
- Silent chest—immediately notify HCP
Quick relief/rescue medications for asthma
used to treat acute attacks
Bronchodilators:
- Short-acting inhaled beta2-adrenergic agonists (SABAs)—all patients should have this
- Inhaled anticholinergics; often used with SABA
Antiinflammatory Drugs
- IV corticosteroids
Long-term control medications for asthma
to achieve and maintain control
Bronchodilators:
- Long-acting inhaled or oral beta2-adrenergic agonists (LABAs)
- Methylxanthines
- Anticholinergics
Antiiflammatory Drugs
- Oral or inhaled corticosteroids (ICS)
- Leukotriene modifiers
- Anti-IgE
Short-acting beta-adrenergic agonists (SABA)
Example: albuterol
- Stimulate beta2 receptors in bronchioles to produce bronchodilation
- Most effective for relieving acute bronchospasm with acute attack
- Onset: minutes and duration: 4 to 8 hours
- Prevent release of inflammatory mediators from mast cells
– Take before exercise to prevent attack
- Too frequent use results in tremors, anxiety, tachycardia, palpitations, and nausea
- Not for long-term use
See: Drug Alert
Long-acting beta2-adrenergic agonist drugs (LABA)
Examples: Salmeterol (Serevent), formoterol (Foradil)
- Added to daily ICSs; combination ICS and LABA available
- Used once every 12 hours; decreases the need for SABAs
- Never used for acute attack
Methylxanthines: asthma
Example: theophylline
- Less effective long-term bronchodilator
- Used only as alternative for LABA
- Many drug interactions and side effects
- Action: unknown
- Narrow margin of safety—monitor blood levels
- Toxicity: nausea, vomiting, seizures, insomnia
Anticholinergic drugs for asthma
- Promote bronchodilation by preventing muscles around bronchi from tightening
- Less effective than SABAs for asthma
– Used more with COPD - Not used in routine management; except for severe acute asthma attacks
Three classes of anti-inflammatory drugs for asthma
Corticosteroids
Leukotriene modifiers
Monoclonal antibodies
- Anti-IgE
- Anti-Interleukin 5
Nonprescription combination drugs
Bronchodilator (ephedrine) and expectorant (guaifenesin)
- OTC —many side effects; should avoid
Epinephrine and ephedrine inhalers
- Stimulate CV and CNS—potentially dangerous
- Ephedrine can be used to produce methamphetamine
- Reformulated with phenylephrine
Inhalation devices for drug therapy for asthma
- Many asthma drugs are given by inhalation
- Faster action
- Fewer systemic side effects
- Devices used to inhale medications:
– Metered dose inhalers (MDI)
– Dry powdered inhaler (DPI) (rinse mouth because risk of thrush)
– Nebulizers
Inhalers
- Teach correct technique and care
- Taking several MDIs leads to confusion
– Provide education - Potential for overuse
– Bronchodilator use of greater than 2 canisters/month should prompt visit to HCP; may need antiiflammatory
Dry Powdered Inhaler (DPI)
Powdered medication; breath activated
Advantages over MDIs:
- Less manual dexterity and inhalation coordination
- No spacer needed
Disadvantages:
- Low FEV1—inadequate inspiration
- Not all common meds available as DPI
- Powder may clump
Rinse mouth out after use
Nebulizers
Machine converts drug solutions into a fine mist for inhalation via face mask or mouthpiece; easy to use
- Requires air compressor or O2 generator
- Provide education for technique and care
Patient teaching related to drug therapy
- Correct administration of drugs
– Name, purpose, dosage, method of administration, and when to use
– Printed instructions - Response to drug therapy; keep diary/log
– Symptoms improving or need help (HCP) - Side effects and actions if occur
- How to clean and care for devices
- Identify factors that affect correct use
– Age, dexterity, psychologic state, affordability, convenience, administration time and preference
– Financial resource: www.needymeds.org - Importance of adhering to management plan
– Continue long-term therapy even when asymptomatic; explain why
Nursing diagnoses and planning goals for asthma
Diagnoses:
- Impaired breathing
- Activity intolerance
- Anxiety
- Lack of knowledge
Overall goals:
- Have minimal symptoms during the day and night
- Maintain acceptable activity levels (including exercise)
- Maintain greater than 80% of personal best PEFR
- Few or no adverse effects of therapy
- Adequate knowledge to carry out plan
insert photo for green, yellow, red asthma plan
COPD incidence
Whites have highest incidence despite higher rates of smoking among other ethnic groups
Hispanics have lower death rates related to COPD than other ethnic groups
Preventable, treatable, often progressive disease characterized by persistent airflow limitation
COPD risk factors
Cigarette smoking
- Clinically significant airway obstruction develops in 20% of smokers
- COPD should be considered in any person who is over 40 with a smoking history of 10 or more pack-years
Infection
Severe, recurring respiratory infections in childhood
HIV
Tuberculosis
Asthma
Air pollution
Occupational
Aging
Genetics
COPD classification and severity of obstruction
Diagnosis of COPD
- FEV1/FVC ratio of < 70%
Severity of obstruction—postbronchodilator FEV1 results
- GOLD 1 Mild
- GOLD 2 Moderate
- GOLD 3 Severe
- GOLD 4 Very severe
- (Global initiative for Chronic Obstructive Lung Disease)
Clinical Manifestations of COPD
Develops slowly
Diagnosis is considered with:
- Chronic cough (intermittent—first symptom)
- Sputum production
- Dyspnea; occurs with exertion and progressive
- Exposure to risk factors
Distinguish from asthma
Chest heaviness
Dyspnea
Chest breather (versus abdominal)
- Use of accessory and intercostal muscles
- Inefficient breathing
Wheezing and chest tightness
Fatigue
Weight loss and anorexia
Prolonged expiratory phase
Decreased breath sounds, wheezing
Barrel chest
Tripod position
Pursed-lip breathing
Peripheral edema (ankles)—right HF
COPD lab values
- Hypoxemia PaO2 < 60 mmHg; SaO2< 88 %
– don’t want to give high levels of oxygen - Hypercapnia PaCO2 > 45 mmHg
- Increased production of red blood cells
- Hemoglobin concentrations may reach 20 g/dL (200 g/L) or more
- Bluish-red color of skin—polycythemia and cyanosis
Complications of COPD
- Pulmonary hypertension
- Cor pulmonale (right-sided heart failure)
- Acute exacerbations
– Patient education
– Manifestations of exacerbations - Acute respiratory failure
– May occur if wait too long to see HCP with exacerbations
Treatment of COPD
Treatment as inpatient or outpatient depends on severity; medical history, current symptoms, hemodynamic stability, O2 requirements, work of breathing, ABG’s and coexisting disease
Treatments:
- SABAs and oral corticosteroids
– Other: anticholinergic, antibiotics, diuretics
- Oxygen
– Noninvasive preferred
Diagnostic studies for COPD
History and physical exam
Spirometry—confirms diagnosis
- FEV1/FVC ratio <70%
Chest x-ray
Serum alpa1-antitrypsin levels
6-minute walk test
- Pulse ox <88% at rest—qualify for supplemental O2
- testing for if able to go home with oxygen
COPD assessment test, COPD questionnaire
ABGs, ECG, Echo, MUGA scan
sputum culture and sensitivity
Interprofessional care for COPD (drug, respiratory, nutrition)
Most treated as outpatients
Hospitalized for complications
- Acute exacerbations
- Acute respiratory failure
Evaluate for exposure to environmental or occupational irritants
Influenza virus vaccine—annually
Pneumococcal vaccine
Smoking cessation
Drug therapy
- Bronchodilators
- Moderate stage: FEV1 < 60%
– Inhaled long-acting anticholinergic (LABA)
– Inhaled corticosteroids (ICS)
- Severe COPD and chronic bronchitis
– Rofumilast (Daliresp)—antiinflammatory drug
Surgical therapy
COPD therapies
- Oxygen therapy
- O2 therapy is used to treat hypoxemia
– Keep O2 saturation > 90% during rest, sleep, and exertion, or PaO2 > 60 mm Hg
– Individualized
– Improves survival
Respiratory care
- Breathing retraining
- Pursed-lip breathing
– Prolongs expiration to reduce bronchial collapse and air trapping
- Diaphragmatic breathing
– Use of diaphragm instead of accessory muscles to achieve maximum inhalation and slow respiratory rate
Respiratory care
- Postural Drainage, Percussion, Vibration
Nutritional therapy
- Malnutrition in COPD patients is multifactorial
- Increased inflammatory mediators
- Increased metabolic rate
- Lack of appetite
- Advanced stages—weight loss is a predicator of poor prognosis
(want to use bronchodilator before eating)
high calorie, high protein
Gerontologic considerations with COPD
Reduced lean body mass and decreased respiratory muscle strength, increased dyspnea, and lower exercise tolerance leads to higher incidence of acute exacerbations
Smoking cessation important
Often have other comorbidities
- Increased complications, stress, and drug interactions
Nursing diagnoses and goals for COPD
Nursing Diagnoses
- Impaired breathing
- Activity intolerance
- Impaired nutritional status
- Difficulty coping
Goals
- Relief from symptoms
- Ability to perform ADLs an improved exercise tolerance
- No complications related to COPD
- Knowledge and ability to implement a long-term treatment plan
- Overall improved quality of life
Nursing implementation: acute and ambulatory care for COPD
Acute care
Hospitalization required for acute exacerbations or complications:
Pneumonia, cor pulmonale, or acute respiratory failure
Degree and severity of underlying respiratory problem should be assessed
Ambulatory care
Patient/caregiver teaching
Pulmonary rehabilitation
Activity considerations
Sexual activity
Sleep
Psychosocial considerations
Pulmonary rehabilitation (PR) is designed to reduce symptoms and improve quality of life
Activity Considerations
Psychosocial Considerations
Sexuality
Sleep
COPD end-of-life considerations
- Symptoms can be managed, but COPD cannot be cured
- End-of-life issues and advanced directives are important topics for discussion
- Palliative care, end-of-life, and hospice care are important in advanced COPD
COPD evaluation: expected outcomes
- Maintain patent airway by effective coughing
- Have an effective rate, rhythm, and depth of respirations
- Have clear breath sounds
- Return to pre-exacerbation baseline respiratory function
- PaCO2 and PaO2 return to levels normal for patient
What is cystic fibrosis?
Autosomal recessive, multisystem disease with altered transport of sodium and chloride ions in and out of epithelial cells of epithelial cells. Primarily affects:
- Lungs
- Pancreas and biliary tract
- Reproductive tract
What is bronchiectasis?
Etiology and pathophysiology
- Permanent, abnormal dilation of medium-sized bronchi due to inflammatory changes
- Destruction of elastic and muscular structures of the bronchial wall
- Cyclical process of inflammation results in damage which results in remodeling
- Colonization of microorganisms (Pseudomonas) results in weakening of walls and pockets of infection
