Week 6: Chronic Obstructive Pulmonary Disease (COPD): lower respiratory disorder

Question 1

What is COPD?

Answer 1

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)

Question 2

Chronic Bronchitis “Blue Bloater”

Answer 2

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

Question 3

Emphysema “Pink Puffer”

Answer 3

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

Question 4

Clinical Manifestations of COPD

Answer 4

• 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

Question 5

Clinical Manifestations of Emphysema

Answer 5

• 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

Question 6

Clinical Manifestations of Chronic Bronchitis

Answer 6

• obese
• have hypoxemia
• appear cyanotic
• excessive mucus production with a productive cough

Question 7

Complications of COPD

Answer 7

• right sided heart failure due to chronic pulmonary hypertension resulting in right ventricular enlargement (cor pulmonale)
• respiratory infection
• secondary spontaneous pneumothorax (SSP)

Question 8

Exacerbation

Answer 8

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

Question 9

Diagnosis of COPD

Answer 9

based on

• patient history
• physical assessment
• and spirometry

Question 10

Diagnostic Procedures

Answer 10

• CT scan of the lungs
• Pulmonary Function Tests (spirometry)
• chest x-ray

Question 11

Pulmonary Function Test

Answer 11

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

Question 12

Spirometry: FEV1

Answer 12

forced expiratory volume in 1 second

-volume of air expired in the first second of maximal expiration after a maximal inspiration

Question 13

Spirometry: FVC

Answer 13

forced vital capacity

-is the maximum volume air exhaled during a forced expiration

Question 14

Laboratory Tests

Answer 14

-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

Question 15

Therapeutic Procedures

Answer 15

• 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

Question 16

Management Plan for COPD has 4 Goals

Answer 16

1. Assess and monitor the disease
2. Reduce modifiable risk factors
3. Manage stable COPD
4. Manage exacerbations

Question 17

Management Plan: Assess and monitor the disease

Answer 17

• 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

Question 18

Management Plan: Reducing modifiable risk factors

Answer 18

• decreasing or eliminating exposure to chemicals, dust, and air pollutants, especially smoke
• most important is smoking cessation

Question 19

Management Plan: Manage stable COPD

Answer 19

-health education regarding the risks and warning signs of an exacerbation, oxygen therapy, moderate exercise as tolerated, and the mainstay of medical management (medications)

Question 20

Pharmacological Management

Answer 20

• 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

Question 21

What is a way to evaluate the effectiveness of treatment and determine a course of therapy?

Answer 21

• 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

Question 22

Risk Factors of Emphysema

Answer 22

• smoking history
• occupational exposure
• environmental exposure
• alpha1-antitrypsin deficiency

Question 23

Risk Factors for Chronic Bronchitis

Answer 23

• smoking history
• occupational exposure
• environmental exposure

Question 24

Secondary Spontaneous Pneumothorax (SSP)

Answer 24

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

Question 25

The clinical manifestations of COPD are due to?

Answer 25

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

Question 26

Nursing Care

Answer 26

• 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

Question 27

Medications: Bronchodilators: Short acting beta2 agonists

Answer 27

-albuterol
-levalbuterol
provide rapid relief

Question 28

Medications: Bronchodilators: Cholinergic antagonists (anticholinergics)

Answer 28

(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

Question 29

Medications: Bronchodilators: Methylxanthines

Answer 29

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

Question 30

Anti-Inflammatories

Answer 30

-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)

Question 31

Mucolytic Agents

Answer 31

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

Question 32

Interprofessional care

Answer 32

• 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

Question 33

Client Education

Answer 33

• 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

Question 34

Health Promotion and Disease Prevention

Answer 34

• 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