Management of Patients With
Chronic Pulmonary Disease
Chronic Obstructive Pulmonary Disease
and Associated Respiratory Diseases
 COPD is a slowly progressive respiratory disease of
airflow obstruction
o Emphysema, chronic bronchitis
o Preventable and treatable but not fully reversible
o Involving the airways, pulmonary parenchyma, or
both
o Cannot get air out
 Other
o Cystic fibrosis, bronchiectasis, asthma
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Pathophysiology of COPD
 Airflow limitation is progressive, with abnormal
inflammatory response to noxious particles or gases
 Chronic inflammation damages tissue
 Scar tissue in airways results in narrowing
 Scar tissue in the parenchyma decreases elastic recoil
(compliance)
 Scar tissue in pulmonary vasculature causes thickened
vessel lining and hypertrophy of smooth muscle
(pulmonary hypertension)
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Risk Factors
 Exposure to tobacco smoke accounts for an estimated
80% to 90% of cases
 Passive smoking (i.e., secondhand smoke)
 Increased age
 Occupational exposure—dust, chemicals Indoor and
outdoor air pollution
 Genetic abnormalities
o deficiency of alpha1-antitrypsin
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Chronic Bronchitis
 Cough and sputum production for at least 3 months in
each of 2 consecutive years
 Ciliary function is reduced, bronchial walls thicken,
bronchial airways narrow, and mucous may plug airways
 Alveoli become damaged, fibrosed, and alveolar
macrophage function diminishes
 The patient is more susceptible to respiratory infections
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Pathophysiology of Chronic Bronchitis
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Emphysema
 Abnormal distention of air spaces beyond the terminal
bronchioles with destruction of the walls of the alveoli
 Decreased alveolar surface area increases in “dead
space,” impaired oxygen diffusion
 Hypoxemia results
 Increased pulmonary artery pressure may cause rightsided heart failure (cor pulmonale)
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Clinical Manifestations of COPD
 Three primary symptoms
o Chronic cough
o Sputum production
o Dyspnea
 Diminished breath sounds, wheezes, crackles
 Accessory muscle use
 Weight loss due to dyspnea
 “Barrel chest”
 ABGs ➡ high PCO2 and low pH
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Normal Chest versus Barrel-Shaped Chest
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Typical Posture of a Person With COPD
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Assessment and Diagnosis of COPD
 Health history, refer to Chart 20-2
 Pulmonary function tests
 Spirometry
 Arterial blood gas
 Chest x-ray
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Complications of COPD
 Respiratory insufficiency and failure
 Pneumonia
 Chronic atelectasis
 Pneumothorax
 Cor pulmonale
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Medical Management
 Promote smoking cessation
 Reducing risk factors
 Managing exacerbations
 Providing supplemental oxygen therapy
 Pneumococcal vaccine
 Influenza vaccine
 Pulmonary rehabilitation
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Oxygen Therapy
 Oxygen via nasal cannula up to 2 lpm…why is this?
o Poor gas exchange leads to hypoxia and hypercapnia
o Chronic hypercapnia ➡ drive to breathe
 Maintain SpO2 88-92%
 What will happen with too much oxygen administration?
o Reduce drive to breathe
o Hypercapneic respiratory failure ➡ narcosis
 Bipap or intubation to reverse hypercapneic respiratory
failure.
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Medications to Treat COPD
 Bronchodilators, MDIs
o Beta-adrenergic agonists
o Muscarinic antagonists (anticholinergics)
o Combination agents
 Corticosteroids
 Antibiotics
 Mucolytics
 Antitussives
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Patient Education
 Pursed lip breathing
 Small frequent meals
 Increase fluids
 Smoking cessation
 Oxygen safety at home
 Avoid triggers and allergens
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Bronchiectasis
 Bronchiectasis is a chronic, irreversible dilation of the
bronchi and bronchioles
 Caused by:
o Airway obstruction, pulmonary infections
o Diffuse airway injury
o Genetic disorders
o Abnormal host defenses
o Idiopathic causes
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Bronchiectasis: Clinical Manifestations
and Medical Management
 Chronic cough
 Purulent sputum in copious amounts
 Clubbing of the fingers
 Postural drainage
 Chest physiotherapy
 Smoking cessation
 Antimicrobial therapy
 Bronchodilators and mucolytics
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Bronchiectasis: Nursing Management
 Focus is on alleviating symptoms and clearing pulmonary
secretions
 Patient teaching
o Smoking cessation
o Postural drainage
o Early signs and symptoms of respiratory infections
o Conserving energy
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Asthma
 Chronic inflammatory disease of the airways that causes
hyperresponsiveness, mucosal edema, and mucus
production
 Inflammation leads to cough, chest tightness, wheezing,
and dyspnea (Fig. 20-10)
 Asthma is largely reversible; spontaneously or with
treatment
 Allergy is the strongest predisposing factor
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Clinical Manifestations
 Cough, dyspnea, wheezing
 Exacerbations
o Cough, productive or not
o Generalized wheezing
o Chest tightness and dyspnea
o Diaphoresis
o Tachycardia
o Hypoxemia and central cyanosis
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Medications Management for Asthma
 Stepwise, refer to Figure 24-7
 Quick-relief medications
o Beta2-adrenergic agonists
o Anticholinergics
 Long-acting medications
o Corticosteroids
o Long-acting beta2-adrenergic agonists
o Leukotriene modifiers
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Patient Teaching
 How to identify and avoid triggers
 Proper inhalation techniques
 How to perform peak flow monitoring
 How to implement an action plan
 When and how to seek assistance
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Cystic Fibrosis
 Most common autosomal recessive disease among the
Caucasian population
 Genetic screening to detect carriers
 Genetic counseling for couples at risk
 Genetic mutation changes chloride transport which leads
to thick, viscous secretions in the lungs, pancreas, liver,
intestines, and reproductive tract
 Respiratory infections are the leading cause of morbidity
and mortality
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Medical Management of CF
 Chronic: control of infections; antibiotics
 Acute: aggressive therapy involves airway clearance and
antibiotics based on results of sputum cultures
 Anti-inflammatory agents
 Corticosteroids; inhaled, oral, IV during exacerbations
 Inhaled bronchodilators
 Oral pancreatic enzyme supplementation with meals
 Cystic fibrosis transmembrane conductance regulator
(CFTR) modulators are a new class of drugs and help to
improve function of the defective CFTR protein
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Nursing Management of CF
 Strategies that promote removal of pulmonary secretions
o CPT and breathing exercises
 Remind patient to reduce risk factors for resp infection
 Adequate fluid and electrolyte intake
 Palliative care
 Discuss end-of-life issues and concerns
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