Respiratory Module

C.O.P.D.

COPD - overview

COPD?– Chronic Obstructive Pulmonary Disease

• COLD?– Chronic Obstructive Lung Disease

• Broad classifications of disease

COPD

• Characterized by – airflow limitation – Irreversible– Dyspnea on exertion– Progressive– Abn. inflammatory response of the lungs to

noxious particles or gases

Pathophysiology

• Noxious particles of gas • Inflammatory response – (occurs throughout the airways, parenchyma and

pulmonary vasculature)

• Narrowing of airway

Pathophysiology

• Injury Repair• Injury repair• Injury repair• Injury Repair• Injury repair scar tissue – Narrowing of lumen

Pathophysiology

• Inflammation • Thickening of the wall of the pulmonary

capillaries• (Smoke damage & inflammatory process)

COPD

• Includes– Emphysema– Chronic bronchitis

• Does not include– Bronchiectasis– Asthma

COPD - FYI

• COPD 4th leading cause of death in the US• 12th leading cause of disability• Death from COPD is on the rise while death

from heart disease is going down

COPD

Risk Factors for COPD• Exposure to tobacco smoke – 80-90% of COPD

• Passive smoking• Occupational exposure• Air pollution

COPD risk factors

• #1– Smoking

• Why is smoking so bad??– ↓ scavenger cell ability– ↓ cilia function– Irritates goblet cells & Mucus glands • ↑ mucus production

Chronic Bronchitis

• Disease of the airway• Definition:– cough + sputum production – > 3 months – 2 consecutive years

Chronic Bronchitis

Pathophysiology• Pollutant irritates airway • Inflammation + secretion of mucus • goblet cells +• mucus secreting glands + Mucus• ciliary function

Chronic Bronchitis

• Plugs become areas for bacteria to grow and chronic infections which increases mucus secretions and eventually, areas of focal necrosis and fibrosis

Chronic Bronchitis

• Bronchial walls thicken– Bronchial Lumen narrows– Mucus plugs airway

• Alveoli/bronchioles become damaged• ↑ alveolar macrophages • ↑ susceptibility to LRI

What do you think?

Exacerbation of Chronic bronchitis is most likely to occur during?

A.Fall B.SpringC.SummerD.Winter

Emphysema

Pathophysiology• Affects alveolar membrane– Destruction of alveolar wall– Loss of elastic recoil– Over distended alveoli

Emphysema

Pathophysiology• Over distended alveoli– Damage to adjacent pulmonary capillaries– dead space– Impaired passive expiration

• Impaired gas exchange

Emphysema

• Impaired gas exchange– impaired expiration• Hypoxemia• CO2 • Hypercapnia• Respiratory acidosis

Emphysema

• Damaged pulmonary capillary bed– pulmonary pressure – work load for right ventricle – Right side heart failure (due to respiratory

pressure) – Cor Pulmonale

COPD Compare and contrast

• Chronic Bronchitis is a disease of the ___________?– Airway

• Emphysema is a disease affecting the ___________?– Alveoli

C.O.P.D.

• Risk factors, S&S, treatment, Dx, Rx - same for Chronic Bronchitis & Emphysema

C.O.P.D.

Clinical Manifestation (primary)

1. Cough2. Sputum production3. Dyspnea on exertion(Secondary)• Wt. loss• Resp. infections• Barrel chest

C.O.P.D.Nrs. Assessment

• Risk factors• Past Hx / Family Hx• Pattern of development• Presence of comobidities• Current Tx• Impact

C.O.P.D. Diagnostic exams/procedures

• Pulmonary function test– Tidal Volume•

– Functional residual•

– Spirometry / FEV (force of expired vol.)•

C.O.P.D. Diagnostic exams/procedures

• Bronchodilator reversibility test– Check FEV – Give Bronchodilator– If improved FEV = Asthma– If no improvement FEV = COPD

• ABG’s– Baseline PaO2

• Rule out other diseases– CT scan– X-ray

C.O.P.D. Medical Management

• Risk reduction– Smoking cessation!• (The only thing that slows down the progression of the

disease!)

C.O.P.D. Rx. therapy

Primary• Bronchodilators• CorticosteriodsSecondary• Antibiotics• Mucolytic agents• Anti-tussive agents

Bronchodilators• Action:– Relieve bronchospasms– Reduce airway obstruction–↑ ventilation

• Route– Metered-dose inhaler– Nedulizer– Oral

Bronchodilators• Frequency– Regularly throughout the day– & PRN– Prophylactically

Bronchodilators

• Examples– Albuterol (Proventil, Ventolin, Volmax)– Metaproterenol (Alupent)– Ipratropium bromide (Atrovent)– Theophylline (Theo-Dur)*

* Oral

Glucocorticoids

• Action– Potent anti-inflammatory agent

• Route– Inhaled– Systemic • (oral or intravenous)

Endocrine FlashbackWhich of the following is an iatrogenic event

secondary to prolonged use of corticosteroid medications?

A.SIADHB.Diabetes InsipidusC.Cushing diseaseD.Addison’s diseaseE.Acromegaly

What electrolyte imbalance is assoc with Cushing Syndrome?

A. HypercalcemiaB. HypocalcemiaC. HypernatremiaD. HyponatremiaE. HyperkalemiaF. Hypokalemia

Corticsteriods

• S/E– Cushing• Moon face• Na+ & H20 retention

– Never discontinue abruptly

• What affect do corticosteroids have of blood sugar levels?

Glucocorticoids

• Examples– Prednisone– Methyprednisone– Beclovent

C.O.P.D. Medical Management

• Treatment– O2• When PaO2 < 60 mm Hg

– Pulmonary rehab• Breathing exercises• Pulmonary hygiene

Nursing Management

• Impaired gas exchange• Ineffective airway clearance• Ineffective breathing patterns• Activity intolerance• Deficient knowledge about self-care• Ineffective coping

Nursing Management

• Impaired gas exchange– Bronchodilators– Corticosteroids– Monitor for side effects– Measure FEV (force of expired volume)– Assess dyspnea– Smoking cessation

Nursing Management

• Ineffective airway clearance– Eliminate pulmonary irritants– Directed cough– Chest physiotherapy– Fluids– Aerosol mists

Nursing Management

• Ineffective breathing patterns– Teach and encourage breathing exercises…

Nursing Management• Breathing exercises

– (usually have shallow, rapid, inefficient breathing)

– Diaphragmatic breathing • ↓rate• ↑ventilation• ↑expelled air

– Pursed lip breathing• Slows respiration• Prevents collapse of small airways• Helps control rate and depth• Relax (↓ anxiety)

Nursing Management• Activity intolerance– Activity pacing

• More fatigued in AM• Plan activities for “best times”

– Physical conditioning• Exercise training

– ↑tolerance– ↓dyspnea– ↓fatigue

• Graded exercise• Regular vs. sporadic

Nursing Management

• Deficient knowledge about self-care– ↑participation (ĉ ↑ improvement)– Coordinate diaphragmatic breathing with

activities– Avoid fatigue– Fluids always available

Knowledge Deficit

• O2 therapy– Flow rate– # hours required– No smoking– Regular blood oxygenation levels– Regular ABG’s

Knowledge Deficit

• Set realistic goals• Modify life style• Avoid temperature extremes– Heat • ↑ O2 demand

– Cold • ↑ bronchospasms

Nursing Management

• Ineffective coping– Set realistic goals– Listen– Empathy– Refer

C.O.P.D.Nursing Management

• Imbalanced Nutrition: Less than Body requirement– (frequently weight loss and protein breakdown)– Monitor weight– ↑Protein – Nutritional supplements

Question?A patient is getting discharged from a SNF facility. The patient has a history

of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient?

A. Deep breathing techniques to increase O2 levels. B. Cough regularly and deeply to clear airway passages. C. Cough following bronchodilator utilization D. Decrease CO2 levels by increase oxygen tank output during meals.

Bronchiectasis

Pathophysiology• Chronic, irreversible, dilation of the bronchi and

bronchioles• Inflammatory process • Damage of bronchial wall • Permanently distended

Bronchiectasis

• Pathophysiology– Form sacs – Secretion pool – Infections

Bronchiectasis Etiology

• 2nd chronic disorder• Pulmonary infection• Aspiration• Bronchus obstruction• Genetic disorder– Cystic fibrosis

Bronchiectasis

Clinical Manifestations• Recurrent LRI• Cough• Sputum

– Copious (>200ml)– Purulent– Foul smelling

• Auscultation– Wheezes– Crackles

Bronchiectasis

• If wide spread – Dyspnea

• Clubbing of the fingers

• pulmonary blood pressure Cor pulmonale

Bronchiectasis

Dx• S&S• Sputum cultures– r/o TB

• CT*

Bronchiectasis

Tx• Bronchodilators• Mucolytic agents• Antibiotics• Surgery• O2– If hypoxemia

• Postural drainage• Chest physiotherapy• Smoking cessation

Asthma Pathophysiology

• Characterized by intermittent airway obstruction

• In response to variety of stimuli – Epithelial lining of the airway respond by

becoming inflamed and edematous– Bronchospasms– Secretions increase in viscosity

Asthma

Pathophysiology• The airway hyper-responsiveness, mucosal edema &

mucus production leads to• Recurrent episodes of symptoms– Cough– Chest tightness– Wheezing– dyspnea

Asthma

What is the strongest predisposing factor for asthma?

A. SmokingB. Family historyC. AllergyD. Having a weird middle name

AsthmaPathophysiology

• Mast-cells play a key role in the inflammatory process

• Alpha– adrenergic receptors trigger broncho-constriction

What is the action of a mast-cell stabilizer

A. Reduces histamine releaseB. Increases the effectiveness of the white

blood cellsC. Increase WBC productionD. Bronchodilatation

Thought question?

Why is Asthma not considered a form of C.O.P.D?

A. Smoking is not a risk factorB. It is not irreversibleC. It doesn’t start with the letter “C”D. It is not a chronic diseaseE. It is not an obstructive disease

AsthmaS&S

Primary• Cough• Dyspnea• Wheezing– Expiratory– Nasal flaring

Asthma

Assessment & Dx• History• Co-mobid conditions– Gastro-esophageal reflux

Asthma

During an Acute episode• Respiratory rate– Increased (initially)

• CO2?– Decreased – Resp. alkalosis

– Tired – Decreased Resp. rate

• CO2 ? – Increased – Resp acidosis

Asthma

• O2 Sats?– Decreased– Cyanosis

• Heart rate– Increased

• Blood Pressure– Increased

• Anxious, feeling of impending doom!

AsthmaPrevention

• Manipulate known triggers– Stress– Pollen

• Exercise

AsthmaRx therapy

2 general classes of asthma medications1. Quick-relief 2. Long-acting• Because of the underlying pathology of asthma is

inflammation, controlled primarily with anti-inflammatory meds

AsthmaRx therapy

• Bronchodilators– Aminophylline

• Anticholinergics– Atropine Sulfate– Atrovent

• Corticosteriods– Prednisone– Decreased inflammation

• Mucolytic agents– Acetylcysteine

Asthma

• Diet– Fluids

• Activity– Rest periods– Relaxation techniques– Not overexert self– Sit down and sip warm water

Status Asthmaticus

• Pathophysiology– Attack lasting > 24 hours– Do not respond to normal treatment

• The term “pink puffer” refers to the client with which of the following conditions?A. ARDSB. AsthmaC. Chronic obstructive bronchitisD. Emphysema

A 66 year old client has marked dyspnea at rest, is thin and uses accessory muscles to breathe. He’s tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. This client has symptoms of which disease?

A. AsthmaB. Chronic BronchitisC. Emphysema

• It’s highly recommended that clients with asthma, chronic bronchitis and emphysema have Pneumovax and flu vaccinations for which of the following reasons?

A. All clients are recommended to have these vaccinesB. These vaccines produce bronchodilation and

improve oxygenationC. These vaccines can reduce tachypnea D. Respiratory infections can cause severe hypoxia and

possible death in these clients

Exercise has which of the following effects on clients with asthma,

chronic bronchitis and emphysema?

A. It enhances cardiovascular fitnessB. It improves respiratory muscle strengthC. It reduces the number of acute attacksD. It worsens respiratory function and is

discouraged

Clients with Chronic Obstructive Bronchitis are given diuretics. Which of the following

best explains why?

A. Reducing fluid volume reduces oxygen demandB. Reducing fluid volume improves the clients mobilityC. Reducing fluid volume reduces sputum productionD. Reducing fluid volume improves respiratory function