Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Focus on Chronic Obstructive Pulmonary Disease
(COPD)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPD Description
• Airflow limitation not fully reversible• Generally progressive• Abnormal inflammatory response of
lungs to noxious particles or gases
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDDescription
• Includes• Chronic bronchitis• Emphysema
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic BronchitisDescription
• Presence of chronic productive cough for 3 or more months in each of 2 successive years • Other causes of chronic cough are
excluded
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
EmphysemaDescription
• Abnormal permanent enlargement of the air space distal to the terminal bronchioles• Destruction of bronchioles without
obvious fibrosis
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDSignificance
• Fourth leading cause of death in the United States• More than 50% die within 10 years
of diagnosis
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDEtiology
• Risk factors• Cigarette smoking• Occupational chemicals and dust• Air pollution
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDEtiology
• Risk factors• Infection • Heredity• Aging
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDOccupational & Environmental• COPD can develop with intense or
prolonged exposure to• Dusts, vapors, irritants, or fumes• High levels of air pollution• Fumes from indoor heating or cooking
with fossil fuels
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDInfection
• Recurring infections impair normal defense mechanisms• Risk factor for COPD• Intensify pathologic destruction of
lung tissue
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDHeredity
-Antitrypsin (AAT) deficiency• Genetic risk factor for COPD• Accounts for <1% to 2% of COPD
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDAging
• Some degree of emphysema is common due to physiological changes of aging lung tissue
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDAging
• Natural changes in the aging lungs• Gradual loss of elastic recoil• Lungs become rounded and smaller• Loss of alveolar supporting structures• Decreased number of functional alveoli
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDAging
• Natural changes in the aging lungs• Decreased arterial O2 levels• Thoracic cage changes from
osteoporosis and calcification of costal cartilage
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDPathophysiology
• Primary process is inflammation• Inhalation of noxious particles• Mediators released cause damage to
lung tissue• Airways inflamed• Parenchyma destroyed
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
EmphysemaPathophysiology
• Two types• Centrilobular• Panlobular
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDMorphology
Fig. 29-8
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
EmphysemaPathophysiology
• Centrilobular (central part of lobule)• Dilation and destruction of respiratory
bronchioles and pulmonary capillary bed• Prominent in upper lobes
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
EmphysemaPathophysiology
• Panlobular (destruction of whole lobule)• Affects respiratory bronchioles,
alveolar ducts, and alveolar sacs• Prominent in lower lobes
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDPathophysiology
• Supporting structures of lungs are destroyed• Air goes in easily, but remains in the
lungs• Bronchioles tend to collapse • Causes barrel-chest look
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDPathophysiology
• Pulmonary vascular changes • Blood vessels thicken• Surface area for diffusion of O2
decreases
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDPathophysiology
• Common characteristics• Mucus hypersecretion• Dysfunction of cilia• Hyperinflation of lungs• Gas exchange abnormalities
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDPathophysiology
• Commonly emphysema and chronic bronchitis coexist• Distinguishing symptoms can be
difficult with comorbidities
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDClinical Manifestations
• Develops slowly• Diagnosis is considered with• Cough• Sputum production• Dyspnea• Exposure to risk factors
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDClinical Manifestations
• Intermittent cough is earliest symptom• Dyspnea usually prompts medical
attention• Occurs with exertion in early stages• Present at rest with advanced disease
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDClinical Manifestations
• Causes chest breathing• Use of accessory and intercostal
muscles• Inefficient
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDClinical Manifestations
• Characteristically underweight with adequate caloric intake• Chronic fatigue
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDClinical Manifestations
• Physical examination findings• Prolonged expiratory phase• Wheezes• Decreased breath sounds• ↑ Anterior-posterior diameter
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDClinical Manifestations
• Bluish-red color of skin• Polycythemia and cyanosis
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPD Complications
• Cor pulmonale• Exacerbations of COPD• Acute respiratory failure• Peptic ulcer disease• Depression/anxiety
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDDiagnostic Studies
• Diagnosis confirmed by pulmonary function tests• Chest x-rays, spirometry, history, and
physical examination are also important in the diagnostic workup
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDDiagnostic Studies
• Spirometry typical findings • Reduced FEV/FVC ratio• Increased residual volume
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDDiagnostic Studies
• ABG typical findings• Low PaO2
• ↑ PaCO2
• ↓ pH• ↑ Bicarbonate level found in late stages
COPD
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPD Diagnostic Studies
• 6-Minute walk test to determine O2
desaturation in the blood with exercise• ECG can show signs of right
ventricular failure
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Primary goals of care• Prevent progression• Relieve symptoms• Prevent/treat complications
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Primary goals of care• Promote patient participation• Prevent/treat exacerbations• Improve quality of life and reduce
mortality risk
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Irritants should be evaluated and avoided• Exacerbations treated promptly
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Smoking cessation• Most effective intervention• Accelerated decline in pulmonary
function slows and usually improves
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Drug therapy• Bronchodilators• Relaxes smooth muscle in the airway• Improves ventilation of the lungs• ↓ Dyspnea and ↑ in FEV1
• Inhaled route is preferred
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Drug therapy• Commonly used bronchodilators
•Β2-Adrenergic agonists• Anticholinergics• Methylxanthines
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPD Collaborative Care
• Drug therapy• Inhaled corticosteroid therapy• Used for moderate-to-severe cases• Not for long-term use
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• O2 therapy is used to• Reduce work of breathing• Maintain PaO2
• Reduce workload on heart
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Long-term O2 therapy improves• Survival• Exercise capacity• Cognitive performance• Sleep in hypoxemic patients
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Humidification • Used because O2 has a drying effect on
the mucosa• Supplied by nebulizers, vapotherm,
and bubble-through humidifiers
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Complications of oxygen therapy• Combustion • CO2 narcosis• O2 toxicity• Absorption atelectasis• Infection
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Chronic O2 therapy at home improves• Prognosis• Mental acuity• Exercise intolerance
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Surgical therapy• Lung volume reduction surgery• Remove 30% of most diseased lung to
enhance performance of remaining tissue
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Surgical therapy• Bullectomy• Used for emphysema• Large bullae are resected to improve lung
function
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Breathing retraining• Decreases dyspnea, improves
oxygenation, and slows respiratory rate• Pursed-lip breathing
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Pursed-lip breathing• Prolongs exhalation and prevents
bronchiolar collapse and air trapping
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Effective coughing• Main goals• Conserve energy• Reduce fatigue• Facilitate removal of secretions
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Nutritional therapy • Weight loss and malnutrition are
common• Pressure on diaphragm from a full
stomach causes dyspnea• Difficulty breathing while eating leads to
inadequate consumption
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Nutritional therapy• To decrease dyspnea and conserve
energy• Rest at least 30 minutes prior to eating• Use bronchodilator• Prepare foods in advance
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Nutritional therapy• Eat 5 to 6 small meals to avoid bloating
and early satiety• Cold foods may cause less fullness than
hot foods
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPDCollaborative Care
• Nutritional therapy• Avoid • Foods that require a great deal of chewing• Exercises and treatments 1 hour before
and after eating• Gas-forming foods
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPD Collaborative Care
• Nutritional therapy• High-calorie, high-protein diet is
recommended• Fluids (intake of 3 L/day) should be
taken between meals
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Assessment
• Obtain complete health history and conduct a complete physical assessment• See Table 29-27 in textbook for COPD
specific information
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Diagnoses
• Ineffective airway clearance• Impaired gas exchange• Imbalanced nutrition: Less than
body requirements• Risk for infection• Insomnia
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementPlanning
• Goals• Prevention of disease progression• Ability to perform ADLs• Relief from symptoms• No complications related to COPD
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementPlanning
• Goals• Knowledge and ability to implement
long-term regimen• Overall improved quality of life
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
• Health promotion • Abstain from or stop smoking• Avoid or control exposure to
occupational and environmental pollutants and irritants
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
• Health promotion • Early detection of small-airway disease• Early diagnosis and treatment of
respiratory tract infections
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
• Health promotion • Awareness of family history of COPD
and AAT deficiency
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
• Acute intervention • Required for pneumonia, cor
pulmonale, or acute respiratory failure• Degree and severity of underlying
respiratory problem should be assessed
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
• Ambulatory and home care• Most important aspect is teaching• Pulmonary rehabilitation• Activity considerations• Sexual activity• Sleep• Psychosocial considerations
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
• Pulmonary rehabilitation• Increase exercise performance• Reduce dyspnea• Improved quality of life
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
• Activity considerations • Exercise training leads to energy
conservation• In upper extremities it may improve
muscle function and reduce dyspnea
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
• Activity considerations• Modify ADLs to conserve energy• Walk 15 to 20 minutes a day at least
three times a week with gradual increases• Adequate rest should be allowed
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
• Sleep• Can be difficult because of
medications, postnasal drip, or coughing• Nasal saline sprays, decongestants, or
nasal steroid inhalers can help
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
• Psychosocial considerations• Healthy coping is difficult • Depression affects 40% as severity and
chronicity are realized
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementNursing Implementation
Ambulatory and home care• Psychosocial considerations• Denial• Dependence• Use relaxation techniques and support
groups
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementEvaluation
• Expected outcomes• Normal breath sounds• Effective coughing• Return of PaO2 to normal range for
patient• Improved mental status
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementEvaluation
• Expected outcomes• Maintenance of normal body weight• Normal serum protein levels• Feeling of being rested• Improvement in sleep pattern
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing ManagementEvaluation
• Expected outcomes• Awareness of need to seek medical
attention• Behaviors minimizing risk of infection• No infection