NUR 342

Management of
Patients with
Chronic

COPD

Chronic obstructive pulmonary disease

A disease state characterized by airflow

limitation that is not fully reversible (GOLD)

COPD is currently the fourth leading cause of

death; mortality from COPD increased among
women; 2005, more women than men died of
COPD.

COPD includes diseases that cause airflow

obstruction (emphysema, chronic bronchitis) or
a combination of these disorders.

Asthma is now considered a separate disorder

but can coexist with COPD.
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Care of the COPD Patient

Chronic Obstructive Pulmonary

Disease (COPD) is a preventable and

treatable disease with some significant
extra- pulmonary effects that may
contribute to the severity in individual
patients. Its pulmonary component is
characterized by airflow limitation that
is not fully reversible. The airflow
limitation is usually progressive and
associated with an abnormal
inflammatory response of the lung to
noxious particles or gases (GOLD
report, 2010).

Pathophysiology of COPD

Airflow limitation is progressive and is associated

with abnormal inflammatory response of the lungs to
noxious agents. Cigarette smoking is a major factor.

Inflammatory response occurs throughout the

airways, lung parenchyma, and pulmonary
vasculature.

Scar tissue and narrowing occur in airways.

Substances activated by chronic inflammation

damage the parenchyma.

Inflammatory response causes changes in

pulmonary vasculature pulmonary hypertension
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Pathophysiology of Chronic
Obstructive Pulmonary Disease
(COPD)

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Chronic Bronchitis

The presence of a cough and sputum production for at

least 3 months in each of 2 consecutive years

Irritation of airways results in inflammation and

hypersecretion of mucus: e. g.smoke, environmental
pollutant

Mucus-secreting glands and goblet cells increase in

number increased mucus production

Ciliary function is reduced, bronchial walls thicken,

bronchial airways narrow, and mucus may plug airways.

Alveoli become damaged and fibrosed, and alveolar

macrophage function diminishes reduces macrophage
ability to destroy particles including bacteria

The patient is more susceptible to respiratory infections.

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Pathophysiology of Chronic
Bronchitis

Emphysema
Abnormal distention of air spaces beyond the

terminal bronchioles with destruction of the

walls of the alveoli

Decreased alveolar surface area causes an

increase in dead space and impaired oxygen

diffusion.

Reduction of the pulmonary capillary bed

increases pulmonary vascular resistance and

pulmonary artery pressures.

Hypoxemia is the result of these pathologic

changes.

Increased pulmonary artery pressure may

cause right-sided heart failure (cor pulmonale).

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Types of Emphysema
Panlobular (paracinar): destruction of

respiratory bronchiole, alveolar duct, &

alveoli.
Manifests barrel chest, DOE, weight loss
Expiration requires muscular effort

Centrilobular (centroacinar): pathologic

changes in center of secondary lobule,

preserving the peripheral portions of
the acinus.
Chronic hypoxemia, hypercapnia,

polycythemia, cor pulmonale

Central cyanosis, peripheral edema, &
respiratory failure.
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Types of Emphysema

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Changes in Alveolar Structure with

Emphysema

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Lung Changes in
Emphysema

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Risk Factors for COPD

Tobacco smoke causes 80-90% of COPD

cases!
Passive smoking
Occupational exposure: dust, chemicals
Ambient air pollution: indoor, outdoor
Genetic abnormalities

Alpha1-antitrypsin deficiency (host risk factor)

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COPD: Clinical
Manifestations
Primary symptoms
Cough
Sputum production
Dyspnea on Exertion (DOE)
COPD with primary emphysema

component

Barrel chest r/t chronic hyperinflation

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Normal Chest Wall and Chest

Wall Changes with Emphysema

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TYPICAL POSTURE OF A
PERSON WITH COPD

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Assessment & Diagnostic

Findings

Health History
Key assessment factors, Chart 24-2, p. 622
Spirometry: used to evaluate airflow obstruction

Determined by ratio of FEV1 (volume of air that

patient can forcibly exhale in 1 second) to forced vital
capacity (FVC).
Obstructive lung disease defined as FEV1/FVC ratio of
<70%
Bronchodilator reversibility testing to r/o asthma

Arterial Blood Gases : check PaO2/PaCO2

CXR: r/o other diseases

Alpha1 antitrypsin deficiency screening with family history of

COPD
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Normal & COPD Patient

Spirogram

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Stages of COPD
4 stages classified by spirometry

Stage I mild
Stage II Moderate
Stage III Severe
Stage IV Very severe
Stage O At risk - chronic cough & sputum,
normal spirometry; deleted from 2010 Gold
report as it is no longer included as a stage
of COPD, as there is incomplete evidence
that individuals who meet the definition of
at risk necessarily progress to Stage I:
Mild COPD

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Medical Management
Risk reduction- smoking cessation
Bronchodilators
Corticosteroids
Influenza and pneumococcal vaccination
Management of exacerbations
Oxygen therapy

PaO2 55mm Hg or less on room air

Monitor respiratory response; CO2 retention &
narcosis
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Medical Management
Risk reduction- smoking cessation
Bronchodilators
Corticosteroids
Influenza and pneumococcal vaccination
Management of exacerbations
Oxygen therapy

PaO2 60mm Hg or less on room air

Monitor respiratory response; CO2 retention &
narcosis
Oxygen therapy is variable in patients with COPD;
its aim is to achieve an acceptable oxygen level
without a fall in pH (increasing hypercapnia)

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Venturi Mask, Nonrebreathing

Mask, Partial Rebreathing Mask

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Teaching a Patient to Use a

Metered Dose Inhaler

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Surgical Management
Bullectomy
Lung Volume Reduction

Surgery
Lung Transplantation

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Nursing Management: Pulmonary

Rehabilitation
Patient education
Breathing exercises
Inspiratory muscle training
Activity pacing
Self-care activities
Physical conditioning
Oxygen and nutritional therapy
Coping measures

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Nursing Process: The Care of

Patients with COPD:
Assessment
Health history
Inspection and exam findings
See Chart 24-2 Assessing patients with COPD
Review of diagnostic tests

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Nursing Process: The Care of

Patients with COPD: Diagnosis
Impaired gas exchange
Impaired airway clearance
Ineffective breathing pattern
Activity intolerance
Deficient knowledge
Ineffective coping

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Collaborative Problems
Respiratory insufficiency or failure
Atelectasis
Pulmonary infection
Pneumonia
Pneumothorax
Pulmonary hypertension

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Nursing Process: The Care of

Patients with COPD: Planning
Smoking cessation
Improved activity tolerance
Maximal self-management
Improved coping ability
Adherence to therapeutic regimen and home

care
Absence of complications
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Improving Gas Exchange/Achieving

Airway Clearance/Improving
Breathing Patterns
Proper administration of bronchodilators

and corticosteroids

Reduction of pulmonary irritants

Directed coughing, huff coughing
Chest physiotherapy
Breathing exercises to reduce air trapping
Diaphragmatic breathing
Pursed-lip breathing

Use of supplemental oxygen

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Improving Activity Tolerance

Focus on rehabilitation activities to improve

ADLs and promote independence.

Pacing of activities
Exercise training
Walking aids
Use a collaborative approach.

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Other Interventions
Set realistic goals.
Avoid extreme temperatures.
Enhance coping strategies.
Monitor for and manage potential

complications.

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Patient Teaching

Disease process

Medications

Procedures

When and how to seek help

Prevention of infections

Avoidance of irritants; indoor and outdoor

pollution and occupational exposure

Lifestyle changes, including cessation of smoking

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Positions for Postural

Drainage

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Chest Percussion

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Bronchiectasis
Chronic, irreversible dilation of

bronchi and bronchioles

Chronic cough and purulent

sputum production

Postural drainage promotes

clearing of secretions

Antibiotics may be prescribed

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Asthma
A chronic inflammatory disease of the

airways that causes hyperresponsiveness,

mucosal edema, and mucus production

Inflammation leads to cough, chest

tightness, wheezing, and dyspnea.

The most common chronic disease of

childhood

Can occur at any age

Allergy is the strongest predisposing factor.
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Pathophysiology of Asthma

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Asthmatic Bronchitis

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Asthma (cont.)
Clinical Manifestations

Cough

Dyspnea

Wheezing

Assessment/Diagnostic findings

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Medications Used for

Asthma
Quick-relief medications
Beta2-adrenergic agonists
Anticholinergics

Long-term medications : controller

medications
See Table 24-4, pp. 641-643

Corticosteroids: Inhaled and systemic

Long-acting beta2-adrenergic agonists
Leukotriene modifiers

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Intermittent
asthma

Consult with asthma specialist if step 4 care or higher is required.

Stepwise approach
for managing
asthma in
Consider consultation
at step 3.
adults and children age 12 and older
Step 5
Preferred:

Step 3
Preferred:

Step 1
Preferred:
SABA PRN

Step 2
Preferred:
Low-dose
inhaled
corticosteroid
(ICS)

Low-dose
ICS +LABA
OR
medium-dose
ICS

Alternative:

Low-dose ICS
+either LTRA,
theophylline,
or zileuton

Cromolyn,
leukotriene
receptor
antagonist
(LTRA),
nedocromil, or
theophylline

Alternative:

Step 4
Preferred:
Medium-dose
ICS +LABA
Alternative:
Medium-dose
ICS +either
LTRA,
theophylline,
or
zileuton

High-dose
ICS +LABA
AND
Consider
omalizumab
for patients
who have
allergies

Step 6
Preferred:

High-dose
ICS +LABA
+oral
corticosteroid
AND
Consider
omalizumab
for patients
who have
allergies

Each step: Patient education, environmental control, and management of comorbidities.

Steps 24: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
(see notes).

Step up if
needed

(first, check
adherence,
environmental
control, and
comorbid
conditions)

Assess
control

Step down if
possible
(and asthma is
well controlled
at least
3 months)

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Examples of Metered-Dose
Inhalers and Spacers

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Using a Peak Flow Meter

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Patient Teaching

The nature of asthma as a chronic inflammatory

disease

Definition of inflammation and bronchoconstriction

Purpose and action of each medication

Identification of triggers and how to avoid them

Proper inhalation techniques

How to perform peak flow monitoring

How to implement an action plan

When and how to seek assistance

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Status Asthmaticus
Pathophysiology
Clinical Manifestations
Assessment & Diagnostic findings
Medical Management
Nursing Management

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Cystic Fibrosis
The most common fatal autosomal recessive

disease among the Caucasian population

Genetic screening can detect carriers of this

disease.

Genetic counseling for couples at risk

A mutation of a gene causes changes in

chloride transport, which leads to thick,

viscous secretions in the lungs, pancreas,
liver, intestines, and reproductive tract.

Pulmonary problems are the leading cause

of morbidity and mortality.

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