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 rightsided heart failure (cor pulmonale).
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Changes in Alveolar Structure with
Emphysema
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Normal Chest Wall and Chest Wall
Changes with Emphysema
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Typical Posture of a Person with COPD
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Risk Factors for COPD
• Tobacco smoke causes 80-90% of COPD cases!
• Passive smoking
• Occupational exposure
• Ambient air pollution
• Genetic abnormalities
– Alpha1-antitrypsin
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pathophysiology of COPD
• Airflow limitation is progressive and is associated with
abnormal inflammatory response of the lungs to noxious
agents.
• 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.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of Patients
with COPD: Assessment
• Health history
• Inspection and exam findings
• See Chart 24-2 and Chart 24-3
• Review of diagnostic tests
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of Patients
with COPD: Diagnosis
• Impaired gas exchange
• Impaired airway clearance
• Ineffective breathing pattern
• Activity intolerance
• Deficient knowledge
• Ineffective coping
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Collaborative Problems
• Respiratory insufficiency or failure
• Atelectasis
• Pulmonary infection
• Pneumonia
• Pneumothorax
• Pulmonary hypertension
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Improving Gas Exchange
• 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
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Improving Activity Tolerance
• Focus on rehabilitation activities to improve ADLs and
promote independence.
• Pacing of activities
• Exercise training
• Walking aids
• Use a collaborative approach.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Other Interventions
• Set realistic goals.
• Avoid extreme temperatures.
• Enhance coping strategies.
• Monitor for and manage potential complications.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
COPD is the ____ leading cause of death in the United
States.
a.First
b.Second
c. Third
d.Fourth
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
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.
• Mucus-secreting glands and goblet cells increase in number.
• 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.
• The patient is more susceptible to respiratory infections.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pathophysiology of Chronic Bronchitis
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
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.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pathophysiology of Asthma
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Medications Used for Asthma
• Quick-relief medications
See Table 24-2
– Beta2-adrenergic agonists
– Anticholinergics
• Long-acting medications
See Table 24-4
– Corticosteroids
– Long-acting beta2-adrenergic agonists
– Leukotriene modifiers
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Which of the following is a methylxanthine bronchodilator?
a. Aminophylline
b. Atrovent
c. Maxair
d. Proventil
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Examples of Metered-Dose Inhalers and
Spacers
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Using a Peak Flow Meter
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins