Copd

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD)

COPDDescriptionCOPDDescription

Characterized by presence of airflow obstruction

Caused by emphysema or chronic bronchitis

Generally progressive May be accompanied by airway

hyperreactivity May be partially reversible

Characterized by presence of airflow obstruction

Caused by emphysema or chronic bronchitis

Generally progressive May be accompanied by airway

hyperreactivity May be partially reversible

Emphysema DescriptionEmphysema Description

Abnormal permanent enlargement of the air space distal to the terminal bronchioles

Accompanied by destruction of bronchioles

Abnormal permanent enlargement of the air space distal to the terminal bronchioles

Accompanied by destruction of bronchioles

Chronic Bronchitis DescriptionChronic Bronchitis Description

Presence of chronic productive cough for

3 or more months in each of 2 successive years in a patient whom other causes of chronic cough have been excluded

Presence of chronic productive cough for

3 or more months in each of 2 successive years in a patient whom other causes of chronic cough have been excluded

COPDCausesCOPDCauses

Cigarette smoking Primary cause of COPD*** Clinically significant airway obstruction

develops in 15% of smokers 80% to 90% of COPD deaths are related

to tobacco smoking > 1 in 5 deaths is result of cigarette

smoking

Cigarette smoking Primary cause of COPD*** Clinically significant airway obstruction

develops in 15% of smokers 80% to 90% of COPD deaths are related

to tobacco smoking > 1 in 5 deaths is result of cigarette

smoking


Cigarette smoking Nicotine stimulates sympathetic nervous

system resulting in: HR Peripheral vasoconstriction BP and cardiac workload

Cigarette smoking Nicotine stimulates sympathetic nervous

system resulting in: HR Peripheral vasoconstriction BP and cardiac workload

COPDCausesCOPDCauses Cigarette smoking

Compounds problems in a person with CAD Ciliary activity Possible loss of ciliated cells Abnormal dilation of the distal air space Alveolar wall destruction Carbon monoxide

O2 carrying capacity Impairs psychomotor performance and judgment

Cellular hyperplasia Production of mucus Reduction in airway diameter Increased difficulty in clearing secretions

Cigarette smoking Compounds problems in a person with CAD Ciliary activity Possible loss of ciliated cells Abnormal dilation of the distal air space Alveolar wall destruction Carbon monoxide

O2 carrying capacity Impairs psychomotor performance and judgment

Cellular hyperplasia Production of mucus Reduction in airway diameter Increased difficulty in clearing secretions


Secondhand smoke exposure associated with: Pulmonary function Risk of lung cancer Mortality rates from ischemic heart

disease

Secondhand smoke exposure associated with: Pulmonary function Risk of lung cancer Mortality rates from ischemic heart

disease


Infection Major contributing factor to the aggravation

and progression of COPD Heredity

-Antitrypsin (AAT) deficiency (produced by liver and found in lungs); accounts for < 1% of COPD cases

Emphysema results from lysis of lung tissues by proteolytic enzymes from neutrophils and macrophages

Infection Major contributing factor to the aggravation

and progression of COPD Heredity

-Antitrypsin (AAT) deficiency (produced by liver and found in lungs); accounts for < 1% of COPD cases

Emphysema results from lysis of lung tissues by proteolytic enzymes from neutrophils and macrophages

Pathophysiology of Chronic Bronchitis and Emphysema

Fig. 28-7

Emphysema PathophysiologyEmphysema Pathophysiology

Hyperinflation of alveoli Destruction of alveolar walls Destruction of alveolar capillary walls Narrowed airways Loss of lung elasticity

Hyperinflation of alveoli Destruction of alveolar walls Destruction of alveolar capillary walls Narrowed airways Loss of lung elasticity


Two types: Centrilobular (central part of lobule)

Most common

Panlobular (destruction of whole lobule)

Usually associated with AAT deficiency

Two types: Centrilobular (central part of lobule)

Most common

Panlobular (destruction of whole lobule)

Usually associated with AAT deficiency


Structural changes are: Hyperinflation of alveoli Destruction of alveolar capillary walls Narrowed, tortuous small airways Loss of lung elasticity

Structural changes are: Hyperinflation of alveoli Destruction of alveolar capillary walls Narrowed, tortuous small airways Loss of lung elasticity


Small bronchioles become obstructed as a result of

Mucus Smooth muscle spasm Inflammatory process Collapse of bronchiolar walls

Recurrent infections production/stimulation of neutrophils and macrophages release proteolytic enzymes alveolar destruction inflammation, exudate, and edema

Small bronchioles become obstructed as a result of

Mucus Smooth muscle spasm Inflammatory process Collapse of bronchiolar walls

Recurrent infections production/stimulation of neutrophils and macrophages release proteolytic enzymes alveolar destruction inflammation, exudate, and edema


Elastin and collagen are destroyed Air goes into the lungs but is unable to

come out on its own and remains in the lung

Causes bronchioles to collapse

Elastin and collagen are destroyed Air goes into the lungs but is unable to

come out on its own and remains in the lung

Causes bronchioles to collapse


Trapped air hyperinflation and overdistention

As more alveoli coalesce, blebs and bullae may develop

Destruction of alveolar walls and capillaries reduced surface area for O2 diffusion

Compensation is done by increasing respiratory rate to increase alveolar ventilation

Hypoxemia usually develops late in disease

Trapped air hyperinflation and overdistention

As more alveoli coalesce, blebs and bullae may develop

Destruction of alveolar walls and capillaries reduced surface area for O2 diffusion

Compensation is done by increasing respiratory rate to increase alveolar ventilation

Hypoxemia usually develops late in disease

EmphysemaClinical ManifestationsEmphysemaClinical Manifestations

Dyspnea Progresses in severity Patient will first complain of dyspnea

on exertion and progress to interfering with ADLs and rest

Dyspnea Progresses in severity Patient will first complain of dyspnea

on exertion and progress to interfering with ADLs and rest

Emphysema Clinical ManifestationsEmphysema Clinical Manifestations

Minimal coughing with no to small amounts of sputum

Overdistention of alveoli causes diaphragm to flatten and AP diameter to increase

Minimal coughing with no to small amounts of sputum

Overdistention of alveoli causes diaphragm to flatten and AP diameter to increase


Patient becomes chest breather, relying on accessory muscles

Ribs become fixed in inspiratory position

Patient becomes chest breather, relying on accessory muscles

Ribs become fixed in inspiratory position


Patient is underweight (despite adequate calorie intake)

Patient is underweight (despite adequate calorie intake)

Chronic BronchitisPathophysiologyChronic BronchitisPathophysiology

Pathologic lung changes are: Hyperplasia of mucus-secreting glands

in trachea and bronchi Increase in goblet cells Disappearance of cilia Chronic inflammatory changes and narrrowing

of small airways Altered fxn of alveolar macrophages

infections

Pathologic lung changes are: Hyperplasia of mucus-secreting glands

in trachea and bronchi Increase in goblet cells Disappearance of cilia Chronic inflammatory changes and narrrowing

of small airways Altered fxn of alveolar macrophages

infections


Chronic inflammation Primary pathologic mechanism

causing changes Narrow airway lumen and reduced

airflow d/t hyperplasia of mucus glands Inflammatory swelling Excess, thick mucus

Chronic inflammation Primary pathologic mechanism

causing changes Narrow airway lumen and reduced

airflow d/t hyperplasia of mucus glands Inflammatory swelling Excess, thick mucus


Greater resistance to airflow increases work of breathing

Hypoxemia and hypercapnia develop more frequently in chronic bronchitis than emphysema

Greater resistance to airflow increases work of breathing

Hypoxemia and hypercapnia develop more frequently in chronic bronchitis than emphysema


Bronchioles are clogged with mucus and pose a physical barrier to ventilation

Hypoxemia and hypercapnia d/t lack of ventilation and O2 diffusion

Tendency to hypoventilate and retain CO2

Frequently patients require O2 both at rest and during exercise

Bronchioles are clogged with mucus and pose a physical barrier to ventilation

Hypoxemia and hypercapnia d/t lack of ventilation and O2 diffusion

Tendency to hypoventilate and retain CO2

Frequently patients require O2 both at rest and during exercise

Chronic Bronchitis PathophysiologyChronic Bronchitis Pathophysiology

Cough is often ineffective to remove secretions because the person cannot breathe deeply enough to cause air flow distal to the secretions

Bronchospasm frequently develops More common with history of smoking

or asthma

Cough is often ineffective to remove secretions because the person cannot breathe deeply enough to cause air flow distal to the secretions

Bronchospasm frequently develops More common with history of smoking

or asthma

Chronic BronchitisClinical ManifestationsChronic BronchitisClinical Manifestations

Earliest symptoms: Frequent, productive cough during

winter Frequent respiratory infections

Earliest symptoms: Frequent, productive cough during

winter Frequent respiratory infections


Bronchospasm at end of paroxysms of coughing Cough Dyspnea on exertion History of smoking Normal weight or heavyset Ruddy (bluish-red) appearance d/t

polycythemia (increased Hgb d/t chronic hypoxemia)) cyanosis

Bronchospasm at end of paroxysms of coughing Cough Dyspnea on exertion History of smoking Normal weight or heavyset Ruddy (bluish-red) appearance d/t

polycythemia (increased Hgb d/t chronic hypoxemia)) cyanosis


Hypoxemia and hypercapnia Results from hypoventilation and

airway resistance + problems with alveolar gas exchange

Hypoxemia and hypercapnia Results from hypoventilation and

airway resistance + problems with alveolar gas exchange

COPDComplicationsCOPDComplications

Pulmonary hypertension (pulmonary vessel constriction d/t alveolar hypoxia & acidosis)

Cor pulmonale (Rt heart hypertrophy + RV failure)

Pneumonia Acute Respiratory Failure

Pulmonary hypertension (pulmonary vessel constriction d/t alveolar hypoxia & acidosis)

Cor pulmonale (Rt heart hypertrophy + RV failure)

Pneumonia Acute Respiratory Failure

COPDDiagnostic StudiesCOPDDiagnostic Studies

Chest x-rays early in the disease may not show abnormalities

History and physical exam Pulmonary function studies

reduced FEV1/FVC and residual volume and total lung capacity

Chest x-rays early in the disease may not show abnormalities

History and physical exam Pulmonary function studies

reduced FEV1/FVC and residual volume and total lung capacity

COPDDiagnostic StudiesCOPDDiagnostic Studies

ABGs PaO2

PaCO2 (especially in chronic bronchitis) pH (especially in chronic bronchitis) Bicarbonate level found in late stages

COPD

ABGs PaO2

PaCO2 (especially in chronic bronchitis) pH (especially in chronic bronchitis) Bicarbonate level found in late stages

COPD

COPDCollaborative CareCOPDCollaborative Care

Smoking cessation Most significant factor in slowing the

progression of the disease

Smoking cessation Most significant factor in slowing the

progression of the disease

COPDCollaborative Care: Drug TherapyCOPDCollaborative Care: Drug Therapy

Bronchodilators – as maintenance therapy -adrenergic agonists (e.g. Ventolin)

MDI or nebulizer preferred Anticholinergics (e.g. Atrovent)

Bronchodilators – as maintenance therapy -adrenergic agonists (e.g. Ventolin)

MDI or nebulizer preferred Anticholinergics (e.g. Atrovent)

COPDCollaborative Care: Oxygen Therapy

COPDCollaborative Care: Oxygen Therapy

O2 therapy

Raises PO2 in inspired air Treats hypoxemia Titrate to lowest effective dose

O2 therapy

Raises PO2 in inspired air Treats hypoxemia Titrate to lowest effective dose

COPD Collaborative Care: Oxygen Therapy

COPD Collaborative Care: Oxygen Therapy

Chronic O2 therapy at home Improved prognosis Improved neuropsychologic function Increased exercise tolerance Decreased hematocrit Reduced pulmonary hypertension

Chronic O2 therapy at home Improved prognosis Improved neuropsychologic function Increased exercise tolerance Decreased hematocrit Reduced pulmonary hypertension

COPDCollaborative Care: Respiratory Therapy


Breathing retraining Pursed-lip breathing

Prolongs exhalation and prevents bronchiolar collapse and air trapping

Diaphragmatic breathing Focuses on using diaphragm instead of accessory

muscles to achieve maximum inhalation and slow respiratory rate

See text re how to teach

Breathing retraining Pursed-lip breathing

Prolongs exhalation and prevents bronchiolar collapse and air trapping

Diaphragmatic breathing Focuses on using diaphragm instead of accessory

muscles to achieve maximum inhalation and slow respiratory rate

See text re how to teach



Huff coughing (Table 28-21) Chest physiotherapy – to bring secretions

into larger, more central airways Postural drainage Percussion Vibration

Huff coughing (Table 28-21) Chest physiotherapy – to bring secretions

into larger, more central airways Postural drainage Percussion Vibration

Positions for Postural Drainage

Fig. 28-16

Positions for Postural Drainage


Encourage patient to remain as active

as possible

Encourage patient to remain as active

as possible


Surgical Therapy Lung volume reduction surgery Lung transplant

Surgical Therapy Lung volume reduction surgery Lung transplant


Nutritional therapy Full stomachs press on diaphragm causing

dyspnea and discomfort Difficulty eating and breathing at the same time

leads to inadequate amounts being eaten

Nutritional therapy Full stomachs press on diaphragm causing

dyspnea and discomfort Difficulty eating and breathing at the same time

leads to inadequate amounts being eaten


Nutritional therapy To decrease dyspnea and conserve energy Rest at least 30 minutes prior to eating Use bronchodilator before meals Select foods that can be prepared in advance 5-6 small meals to avoid bloating Avoid foods that require a great deal of chewing Avoid exercises and treatments 1 hour before and

after eating

Nutritional therapy To decrease dyspnea and conserve energy Rest at least 30 minutes prior to eating Use bronchodilator before meals Select foods that can be prepared in advance 5-6 small meals to avoid bloating Avoid foods that require a great deal of chewing Avoid exercises and treatments 1 hour before and

after eating


Nutritional therapy Avoid gas-forming foods High-calorie, high-protein diet is

recommended Supplements Avoid high carbohydrate diet to prevent

increase in CO2 load

Nutritional therapy Avoid gas-forming foods High-calorie, high-protein diet is

recommended Supplements Avoid high carbohydrate diet to prevent

increase in CO2 load

Nursing ManagementNursing DiagnosesNursing ManagementNursing Diagnoses

Ineffective airway clearance Impaired gas exchange Imbalanced nutrition: less than body

requirements Disturbed sleep pattern Risk for infection

Ineffective airway clearance Impaired gas exchange Imbalanced nutrition: less than body

requirements Disturbed sleep pattern Risk for infection

Nursing ManagementNursing ImplementationNursing ManagementNursing Implementation

Health Promotion STOP SMOKING!!! Avoid or control exposure to occupational

and environmental pollutants and irritants Early detection of small-airway disease Early diagnosis of respiratory tract

infections

Health Promotion STOP SMOKING!!! Avoid or control exposure to occupational

and environmental pollutants and irritants Early detection of small-airway disease Early diagnosis of respiratory tract

infections


Acute Intervention Required for complications like pneumonia,

cor pulmonale, and acute respiratory failure

Acute Intervention Required for complications like pneumonia,

cor pulmonale, and acute respiratory failure


Ambulatory and Home Care Pulmonary rehabilitation

Control and alleviate symptoms of pathophysiologic complications of respiratory impairment

Ambulatory and Home Care Pulmonary rehabilitation

Control and alleviate symptoms of pathophysiologic complications of respiratory impairment


Ambulatory and Home Care Teach patient how to achieve optimal capability

in carrying out ADLs Physical therapy Nutrition Education

Activity considerations Exercise training of upper extremities to help

improve function and relieve dyspnea

Ambulatory and Home Care Teach patient how to achieve optimal capability

in carrying out ADLs Physical therapy Nutrition Education

Activity considerations Exercise training of upper extremities to help

improve function and relieve dyspnea


n Ambulatory and Home Care n Explore alternative methods of ADLs

Encourage patient to sit while

performing activities Coordinated walking

n Ambulatory and Home Care n Explore alternative methods of ADLs

Encourage patient to sit while

performing activities Coordinated walking


Ambulatory and Home Care Slow, pursed-lip breathing After exercise, wait 5 minutes before

using -adrenergic agonist MDI

Ambulatory and Home Care Slow, pursed-lip breathing After exercise, wait 5 minutes before

using -adrenergic agonist MDI


Ambulatory and Home Care Sexual activity

Plan during part of day when breathing is best Slow, pursed-lip breathing Refrain after eating or other strenuous

activity Do not assume dominant position Do not prolong foreplay

Ambulatory and Home Care Sexual activity

Plan during part of day when breathing is best Slow, pursed-lip breathing Refrain after eating or other strenuous

activity Do not assume dominant position Do not prolong foreplay


Ambulatory and Home Care Sleep

Nasal saline sprays Decongestants Nasal steroid inhalers Long-acting theophylline

Decreases bronchospasm and airway obstruction

Ambulatory and Home Care Sleep

Nasal saline sprays Decongestants Nasal steroid inhalers Long-acting theophylline

Decreases bronchospasm and airway obstruction


Ambulatory and Home Care Psychosocial considerations

Guilt Depression Anxiety Social isolation Denial Dependence Use relaxation techniques and support groups

Ambulatory and Home Care Psychosocial considerations

Guilt Depression Anxiety Social isolation Denial Dependence Use relaxation techniques and support groups


Ambulatory and Home Care Discourage moving to places above 4000

ft.

Ambulatory and Home Care Discourage moving to places above 4000

ft.

Health & Medicine

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