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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