Chronic Obstructive Pulmonary Disease COPD and Nursing Lecture

Chronic Obstructive Pulmonary Disease
– Airflow in the lungs is obstructed.
– Decreased resistance to inspiration and increased resistance to expiration.
– Prolonged expiratory phase of respiration.
– COPD is a group of pulmonary diseases with symptoms of chronic cough and expectoration, dyspnea and impaired expiratory airflow. (Emphysema, chronic bronchitis, bronchiectasis, asthma.)
– 4th leading cause of death.
– 2nd leading cause of disability after cardiac disease.Pulmonary Function Tests
•    Tidal volume (VT) – volume of air inhaled and exhaled with normal respiration. 500-700ml/breath.
•    Vital capacity (VC) – amount of air maximally exhaled following maximal inspiration. 4500-4700ml.
•    Inspiratory reserve volume  (IRV) – volume of air that can be forcefully inhaled – 3000ml.
•    Expiratory reserve volume (ERV)  – volume of air that can be forcefully exhaled.
•    Inspiratory capacity (IC)– maximal amount of air inhaled after normal exhalation. (VT + IRV).
•    Residual volume(RV) – volume of air in lungs after a full exhalation – 1200ml.
•    Functional residual capacity (FRC) – volume of air in the lungs after a normal resting exhalation –(ERV+RV).
•    Forced expiratory volume (FEV)– volume of air exhaled forcefully at timed intervals. Measured in seconds.
•    Total lung capacity (TLC) – amount of air in the lungs at the end of maximal inhalation (RV+VC).
Chronic Bronchitis
•    It is a prolonged inflammation of the bronchi, accompanied by chronic cough and excessive production of mucus for atleast 3 months a year for 2 consecutive years.
Causes:
•    chronic bronchial asthma,
•    acute respiratory tract infection (influenza, pneumonia).
•    Air pollution.
•    Smoking.

Pathophysiology
Hypersecretion of mucus and chronic respiratory tract infection

Ability of cilia to propel secretions upward is altered

Secretions remain in lungs, form plugs in bronchi

Bacterial growth and chronic infection

Increases mucus secretion

Death of tissue.
Signs and symptoms of Chronic Bronchitis
•    Chronic cough productive of thick white mucus (morning, evening).
•    Later sputum- yellow, purulent, copious, blood streaked.
•    Bronchospasms.
•    Dyspnea, wheezing.
•    Use of accessory muscles.
•    Prolonged expiration.
•    Hypoxemia
•    Cyanosis.
•    Orthopnea.
•    Tachycardia.
•    Right sided heart failure.

Diagnostic findings
•    Based on history and physical examination.
•    Pulmonary function tests – ↓VC,↓FEV, ↑RV, ↑TLC.
•    ABG – ↑pCO2, hypoxemia, hypercapnia..
•    Severe hypoxemia → polycythemia (overproduction of erythrocytes) and cyanosis.
•    Pulmonary hypertension and CHF in severe cases.
*    Chest X ray – (signs of fluid overload and consolidation), enlarged heart.

Medical Management of Chronic Bronchitis
•     Prevent recurrent infection, maintain function of bronchioles, assist removal of secretions.
•     Stop smoking
•     Bronchodilators to relieve bronchospasm, reduce obstruction, remove secretions.
•    Increased fluid intake.
•    Well balanced diet.
•    Postural drainage and chest percussion.
•    Steroid therapy ( if other therapy fails)
•    Change of occupation.
•    Antibiotic therapy

Nursing Management of Chronic Bronchitis
•    Identify and eliminate environmental irritants – stop smoking, occupation counseling, avoid exposure to cold and wind
•    Prevent infection – avoid visitors with URTI, pneumonia and flu vaccine.
•    Monitor for signs of infection.
•    Proper use of aerosolized bronchodilators and corticosteroids (MDI).
•    Postural drainage.
•    Well balanced diet.
•    Increase fluid intake.
•    Plenty of rest.
•    Moderate aerobic activity

Bronchiectasis

   Definition : Chronic irreversible dilatation of the bronchi and bronchioles.
Causes :
•    Bronchial obstruction by tumor or foreign body
•    Congenital abnormalities.
•    Exposure to toxic gases.
•    Chronic pulmonary infections.
Pathophysiology :
    Airway clearance is impeded → infection in the walls of the bronchi and bronchioles → changes in the structure of the wall tissue → formation of saccular dilatations which collect purulent material → airway clearance further impaired → alveoli distal to obstruction collapse (atelectasis) → scar tissue replaces functioning lung tissue.

Assessment
•     Chronic cough productive of copious amounts of purulent sputum.
•    Hemoptysis.
•    Clubbing of fingers.
•    Repeated lung infections
•    Signs of respiratory insufficiency
*    Decreased vital capacity
*    Hypoxemia
•    Fatigue,
•    Weight loss
•    Anorexia and
•    Dyspnea
Sputum when collected settles in 3 different layers :
Top layer – frothy and cloudy
Middle layer – clear saliva.
Bottom layer – heavy, thick and purulent.
Diagnostics tests :
•    Chest Xray and bronchoscopy – ↑size of bronchioles, areas of atelectasis.
•    Sputum C/S – causative organism
•    Pulmonary function tests

Medical management :
•    Antibiotics for infection.
•    Bronchodilators.
•    Mucolytics.
•    Humidification
•    Drainage of purulent material from bronchi
•    Surgical removal if confined to a small area.
•    Vaccine for influenza and pneumococcus.
Nursing Management : Instruct on postural drainage techniques with chest percussion and vibration.

Pulmonary Emphysema

Emphysema is a chronic disease characterized by abnormal distention and destruction of the walls of the alveoli.
•    Causes permanent lung damage & disability.
•    End stage of many years of damage.
•     Major cause – smoking.

Pathophysiology of Pulmonary Emphysema
Pathophysiology of Pulmonary Emphysema

•    Chronic obstruction to inflow and outflow of air results in state of chronic hyperexpansion.
•    Expiration becomes active (instead of involuntary and passive) and requires muscular effort.
•    Chest becomes rigid, chronic hyperinflation leads to barrel shaped chest
*    Ribs become fixed in inspiratory position.
*    Loss of lung elasticity.
•    Normal expiration becomes impossible

Signs and symptoms of Pulmonary Emphysema
•    Long history of smoking (20yrs)
•    SOBOE (exertional dyspnea)(can’t walk, eat, bathe; anorexia, weight loss, inactivity).
•    Chronic cough productive of mucopurulent sputum.
•    Difficult inspiration & prolonged and difficult expiration.
•    Barrel shaped chest.
•    Use of accessory muscles.
•    Wheezing, crackles, decreased breath sounds.
•    Diminished or muffled heart sounds.
•    Pursed lip breathing
•    Pale anxious and withdrawn.
•    Speaks in short jerky sentences.
•    Distended neck veins
Advanced stages:
•    Memory loss drowsiness, confusion – if untreated leads to carbon dioxide narcosis(lethargy, stupor, coma).
Diagnostic findings
•    Chest X ray – hyperinflated lung fields.
•    PFT –↑ TLC, ↑RV, ↓VC, ↓FEV
•    ABG – hypoxemia, respiratory acidosis.
Medical Management of Pulmonary Emphysema
    Goal – to improve quality of life, slow disease progression, treat obstructed airways.
•    Bronchodilators, Aerosol therapy, Antibiotics, Corticosteroids.
•    Chest physiotherapy.
•    Oxygen to raise pO2 to 65-80.
•    Pulmonary rehabilitation.
•    Stop smoking.

Nursing Management
Assess :
•    respiratory rate, pattern, effort – dyspnea, SOBOE
•    Breath sounds.
•    Barrel shaped chest.
•    Activity tolerance.
•    Characteristics of sputum.
•    s/s of infection.
Administer O2 at 2-3 l/min.
Teach  therapeutic breathing exercises:
–    abdominal breathing, blowing candles at various distances, blowing at objects, pursed lip breathing.
•    Ineffective airway clearance r/t bronchoconstriction, increased mucus production, ineffective cough.
•    Impaired gas exchange r/t prolonged expiration, loss of lung tissue elasticity, and atelectasis.
•    Potential complication of atelectasis.
Asthma
•    Chronic inflammatory disease of the airways resulting in :
–    Airway hyper-responsiveness,
–    Mucosal edema,
–    Mucus production.
•    Leads to recurrent episodes of asthma symptoms
–    Cough
–    Chest tightness.
–    Wheezing and dyspnea.
Types of Asthma :
•    Allergic asthma (extrinsic) – occurs in response to allergens – pollens, dust, animal danders.
•    Idiopathic  (intrinsic) – URTI, emotional upsets, exercise.
•    Mixed – most common and has characteristics of both allergic and idiopathic asthma.
Pathophysiology of asthma
•    Acute exacerbations with symptoms free periods.
•    Predisposing factors:
–    Allergy
–    Chronic exposure to irritants
•    Triggers :
–    Irritants(pollution, cold, weather changes, smoke), exertion, stress, sinusitis.
•    Diffuse airway inflammation → mucosal edema → reducing airway diameter.
•    Contraction of bronchial smooth muscle further narrows airway.
•    Increased mucus production – thick, tenacious
•    Alveoli hyperinflate
•    Inflammatory cells play key role causing increased blood flow, vasoconstriction and bronchoconstriction.
Signs and symptoms of asthma
•    Cough.
•    Dyspnea and wheezing,
•    Chest tightness.
•    Expiration requires effort and is prolonged.
•    Hypoxemia.
•    Central cyanosis
•    Diaphoresis
•    Tachycardia.

Medical Management of Asthma
• Diagnosis:
-Periodic symptoms of obstruction
-Environmental factors associated with symptoms
-Blood tests ( ↑esinophils, IgE)
-FEV and FVC markedly decreased, but improve with bronchodilators. Normal between exacerbations.
• Medications
-Long term (corticosteroids- Azmacort, bronchodilators via MDI)
Quick relief (beta-adrenergic, anticholinergics- atrovent)
Nursing Management of asthma
•    Oxygen in sitting position.
•    Rest
•    Increased fluid intake
•    Monitor for side effects of drugs (adrenergic agents – palpitations, nervousness, pallor, trembling, insomnia).
•    Teach use of peak flow meter.
•    Identify and avoid exposure to triggering events.
•    Teach relaxation techniques, therapeutic breathing techniques.

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