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 Injury Injury Injury Injury Repair repair repair Repair 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 + K secretion of mucus K goblet cells + K mucus secreting glands + KMucus L 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. Spring C. Summer D. 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 K dead space Impaired passive expiration

Impaired gas exchange

Emphysema
Impaired gas exchange
impaired expiration
Hypoxemia K CO2 Hypercapnia Respiratory acidosis

Emphysema
Damaged pulmonary capillary bed
K pulmonary pressure K 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. Cough 2. Sputum production 3. 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
L

Functional residual
K

Spirometry / FEV (force of expired vol.)

L

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 Corticosteriods Secondary
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 Flashback
Which of the following is an iatrogenic event secondary to prolonged use of corticosteroid medications? A. SIADH B. Diabetes Insipidus C. Cushing disease D. Addison s disease E. Acromegaly

What electrolyte imbalance is assoc with Cushing Syndrome? A. B. C. D. E. F. Hypercalcemia Hypocalcemia Hypernatremia Hyponatremia Hyperkalemia 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 Slows respiration Prevents collapse of small airways Helps control rate and depth Relax ( anxiety)

Pursed lip breathing

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 ( 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 bronchospasms

Cold

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 K 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 & K mucus production leads to Recurrent episodes of symptoms
Cough Chest tightness Wheezing dyspnea

Asthma
What is the strongest predisposing factor for asthma? A. Smoking B. Family history C. Allergy D. Having a weird middle name

Asthma Pathophysiology
Mast-cells play a key role in the inflammatory process Alpha adrenergic receptors trigger bronchoconstriction

What is the action of a mast-cell stabilizer

A. Reduces histamine release B. Increases the effectiveness of the white blood cells C. Increase WBC production D. Bronchodilatation

Thought question?
Why is Asthma not considered a form of C.O.P.D? A. Smoking is not a risk factor B. It is not irreversible C. It doesn t start with the letter C D. It is not a chronic disease E. It is not an obstructive disease

Asthma S&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!

Asthma Prevention
Manipulate known triggers
Stress Pollen

Exercise

Asthma Rx therapy
2 general classes of asthma medications 1. Quick-relief 2. Long-acting Because of the underlying pathology of asthma is inflammation, controlled primarily with antiinflammatory meds

Asthma Rx 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. B. C. D. ARDS Asthma Chronic obstructive bronchitis 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. Asthma B. Chronic Bronchitis C. 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 vaccines B. These vaccines produce bronchodilation and improve oxygenation C. 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. B. C. D. It enhances cardiovascular fitness It improves respiratory muscle strength It reduces the number of acute attacks It worsens respiratory function and is discouraged

Clients with Chronic Obstructive Bronchitis are given diuretics. Which of the following best explains why?
A. B. C. D. Reducing fluid volume reduces oxygen demand Reducing fluid volume improves the clients mobility Reducing fluid volume reduces sputum production Reducing fluid volume improves respiratory function