Week 6: Chronic Obstructive Pulmonary Disease (COPD): lower respiratory disorder Flashcards
What is COPD?
Chronic Obstructive Pulmonary Disease
- characterized by exacerbations occurring after exposure to pollutants such as smoke or respiratory infections such as a cold or flu
- composed of 2 diseases; emphysema and chronic bronchitis
- airflow limitations
- irreversible
- airflow limitation is progressive and is associated with an abnormal inflammatory response of the lung to noxious particles or gases
- chronic airflow limitation is caused by a mixture of small-airway disease (chronic bronchitis) and destruction of lung tissue (emphysema)
Chronic Bronchitis “Blue Bloater”
affects the small airways and is defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years
- caused by inflammation of the bronchi and bronchioles by chronic (long) exposure to smoke and environmental irritants
- the inflammation causes an increase in the production of mucus cells, which produces a large amount of thick mucus
- the walls of the bronchus thicken, causing airway obstruction
- the smaller airways are usually affected before the larger airways
- also identified as an asthma-COPD overlap syndrome (ACOS) which significantly impacts disease trajectory and quality of life
Emphysema “Pink Puffer”
disease caused by the destruction of the alveoli
- alveoli enlarge (hyperinflation) and loose elasticity
- inhaled pollutants (smoke, dust, chemicals, air pollution) result in breakdown of elastin, which causes the alveoli to lose their elasticity and thus effective elastic recoil after exhalation
- the small airways collapse prematurely, causing trapping of air in the alveoli and subsequent distension
- carbon dioxide can not leave the alveoli, and oxygen cannot enter, resulting in ineffective exchange
- the patient is hypoxemic, as evidenced by low SpO2 and PaO2, and has carbon dioxide retention and respiratory acidosis
Clinical Manifestations of COPD
- chronic dyspnea
- respiratory rate can reach 40 to 50/min during acute exacerbations
- increased work of breathing
- SOB
- use of accessory muscles and assuming a tripod position to help ease the work of breathing
- pursed-lip breathing
- dyspnea upon exertion
- productive cough that is most severe upon rising in the morning
- hypoxemia
- crackles and wheezes
- rapid and shallow respirations
- barrel chest or increased chest diameter (with emphysema)
- hyperresonance on percussion due to trapped air (emphysema)
- irregular breathing pattern
- thin extremities and enlarged neck muscles
- dependent edema secondary to right-sided heart failure
- clubbing of fingers and toes (late stages of disease)
- pallor and cyanosis of nail beds and mucous membranes (late stages of disease)
- decreased oxygen saturation levels
- in older adults or clients who have dark-colored skin, oxygen saturation can be slightly lower
Clinical Manifestations of Emphysema
- appears thin
- “barrel chest”, in which the ratio of the anteroposterior (AP) diameter to the transverse diameter of the chest is 2:2 rather than the normal ratio of 1:2
- reddish complexion
- appear to be puffing when breathing
Clinical Manifestations of Chronic Bronchitis
- obese
- have hypoxemia
- appear cyanotic
- excessive mucus production with a productive cough
Complications of COPD
- right sided heart failure due to chronic pulmonary hypertension resulting in right ventricular enlargement (cor pulmonale)
- respiratory infection
- secondary spontaneous pneumothorax (SSP)
Exacerbation
a change in the natural course of the disease evidenced by a variation from the patients daily baseline symptoms of dyspnea, cough, and/ or sputum production
- acute in onset
- warning signs: increasing SOB, wheezing, more frequent or severe cough, anxiety, problems with sleep, and decreased appetite
Diagnosis of COPD
based on
- patient history
- physical assessment
- and spirometry
Diagnostic Procedures
- CT scan of the lungs
- Pulmonary Function Tests (spirometry)
- chest x-ray
Pulmonary Function Test
done by spirometry
-Forced vital capacity (FVC)
-Forced expiratory volume in 1 second (FEV1)
(diagnosis based on both the value of FEV1 and FEV1/FVC)
-measurement of the lung’s ability to empty quickly
Spirometry: FEV1
forced expiratory volume in 1 second
-volume of air expired in the first second of maximal expiration after a maximal inspiration
Spirometry: FVC
forced vital capacity
-is the maximum volume air exhaled during a forced expiration
Laboratory Tests
-hematocrit levels; increased due to low oxygen levels
-use sputum cultures and WBC counts to diagnose acute respiratory infections
-ABGs
>hypoxemia (decreased PaO2 less than 80 mmHg)
>hypercarbia (increased PaCO2 greater than 45 mmHg)
-blood electrolytes
Therapeutic Procedures
- chest physiotherapy uses percussion and vibration to mobilize secretions
- raising the foot of the bed slightly higher than the head can facilitate optimal drainage and removal of secretions by gravity
- humidifiers can be useful for who live in dry climate or who use dry heat during the winter
Management Plan for COPD has 4 Goals
- Assess and monitor the disease
- Reduce modifiable risk factors
- Manage stable COPD
- Manage exacerbations
Management Plan: Assess and monitor the disease
- regular pulmonary function tests and chest x-rays with an exacerbation to identify other thoracic abnormalities or progressive changes within the structure of the lungs
- Pulse oximetry (SpO2); to determine the severity of the hypoxemia during an exacerbation
- ABGs to measure the lungs ability to clear carbon dioxide (PaCo2) and acid-base balance; also evaluate oxygen through PaO2 values and help identify the patients response to oxygen therapy and medications
- sputum cultures are assessed to identify organisms causing an infectious trigger to an exacerbation
Management Plan: Reducing modifiable risk factors
- decreasing or eliminating exposure to chemicals, dust, and air pollutants, especially smoke
- most important is smoking cessation
Management Plan: Manage stable COPD
-health education regarding the risks and warning signs of an exacerbation, oxygen therapy, moderate exercise as tolerated, and the mainstay of medical management (medications)
Pharmacological Management
- bronchodilators: beta 2-adrenergic agonists and anticholinergics used individually or in combination on an as-needed or regular basis to control symptoms
- a way to evaluate the effectiveness of treatment and determine a course of therapy is to administer a bronchodilator treatment after the initial spirometry and then repeat the test
- medication management progresses as the disease progresses and begins with inhaled bronchodilators on an as-needed basis
- as disease worsens, long-term bronchodilators are added
- inhaled glucocorticoids are added when and if the patient experiences frequent exacerbations
What is a way to evaluate the effectiveness of treatment and determine a course of therapy?
- administer a bronchodilator after the initial spirometry and then repeat the test
- this approach helps determine how the lungs respond to the bronchodilator or ho the pulmonary obstruction is reversed with medication
Risk Factors of Emphysema
- smoking history
- occupational exposure
- environmental exposure
- alpha1-antitrypsin deficiency
Risk Factors for Chronic Bronchitis
- smoking history
- occupational exposure
- environmental exposure
Secondary Spontaneous Pneumothorax (SSP)
complication of COPD
- occurs in patients with underlying lung disease
- caused by rupture of the hyperinflated alveoli or blebs
- present with dyspnea and chest pains
- more severe with primary spontaneous pneumothorax
- Treatment: supplemental oxygenation and chest tube placement to remove air from the pleural space to allow re-expansion of the affected lung
The clinical manifestations of COPD are due to?
increased airway resistance, increased work of breathing, and increased sputum production
- cough
- increased sputum production
- dyspnea
- use of accessory muscles
- tripod positioning
- inability to talk in full sentences
- pursed-lip breathing
- changes in skin coloring
- anxiety
Nursing Care
- position client to maximize ventilation (high-fowlers)
- encourage effective coughing, or suction to remove secretions
- encourage deep breathing and use of a an incentive spirometer
- administer breathing treatments and medications
- administer oxygen as prescribed; In COPD low arterial levels of oxygen serve as primary drive for breathing (Low PaO2)
- clients who have COPD can need 2 to 4L/min of oxygen via nasal canula or up to 40% via venturi mask; clients who have chronically increased PaCO2 levels usually require 1 to 2L/ min of oxygen via nasal cannula
- monitor for skin breakdown around the nose and mouth from the oxygen device
- promote adequate nutrition
- monitor weight and notice any changes
- instruct patient to practice breathing techniques to control dyspneic episodes
- instruct pursed-lip breathing
- positive expiratory pressure device
- exercise conditioning
- provide support to client and family
- increase fluid intake; drink 2 to 3 L/day to liquefy mucous
Medications: Bronchodilators: Short acting beta2 agonists
-albuterol
-levalbuterol
provide rapid relief
Medications: Bronchodilators: Cholinergic antagonists (anticholinergics)
(Anticholinergics)
- ipratropium (short), block the parasympathetic nervous system. allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions
- tiotropium (long), used to prevent bronchospasm
Medications: Bronchodilators: Methylxanthines
theophylline
- relax smooth muscles of the bronchi
- require close monitoring of blood medication levels due to narrow therapeutic ranges
- use only when other treatments are ineffective
Anti-Inflammatories
-fluticasone, beclomethasone (inhaled)
-prednisone (oral)
-hydrocortisone, methylprednisone (IV)
>decrease airway inflammation
>if corticosteroids, such as fluticasone and prednisone are given systemically, monitor for serious adverse effects (immunosuppression, fluid retention, hyperglycemia, hypokalemia, poor wound healing)
-Leukotriene antagonists (montelukast)
Mucolytic Agents
help thin secretions, making them easier for the client to expel
- nebulizer treatment include acetylcysteine
- guaifenesin is an oral expectorant that can be taken
- a combination of guaifenesin and dextromethorphan (non-opioid antitussive) can be taken orally to loosen secretions
Interprofessional care
- consult respiratory services for inhalers, breathing treatments, and suctioning for airway management
- consult rehabilitative care if the client has prolonged weakness and needs assistance with increasing activity level
- contact nutritional services for weight loss or gain related to medications or diagnosis
- set up referral services; homecare, portable oxygen
- provide support to client and family
Client Education
- eat high-calorie foods to promote energy
- rest as needed
- practice hand hygiene to prevent infection
- take medications (inhalers, oral medications) as prescribed
- stop smoking if needed
- obtain immunizations, such as influenza and pneumonia, to decrease risk of infection
- Use oxygen as prescribed. Inform other caregivers not to smoke around the oxygen due to flammability
- acute infections and other complications require hospital stays. report unusual findings or concerns to the provider
- ensure fluid intake of at least 2 L (68 oz) daily to thin secretions, unless provider recommends otherwise
Health Promotion and Disease Prevention
- promote smoking cessation
- avoid exposure to second-hand smoke
- use protective equipment, such as mask, and ensure proper ventilation while working in environments that contain carcinogens or particles in the air
- influenza and pneumonia immunizations are important for all clients with COPD, but especially for older adults
