CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE LUNG DISEASES ASTHMA CHRONIC BRONCHITIS EMPHYSEMA FULL ASTHMA Dr.Sarma@works REVERSIBILITY OF AIR WAY OBSTRUTION 2 NONE COPD PREVALENCE of MORTALITY (2000) Cause Deaths • In 2000, the WHO estimated 2.74 million COPD deaths worldwide. CHD 724,269 Cancer 534,947 CVA 158,060 cause of death. • It is expected to be the third leading cause of death by 2020. COPD 1,14,318 • 10 lacs Indians die in a year due to smoking related diseases. • In India, 4,00,000 premature deaths annually due to use of biomass fuels, like cow dung cakes, open fires Accidents 94,828 Diabetes 64,574 *The • In 1990, COPD was ranked 12th leading Indian J Chest Dis & Allied Sciences 2009; 43:139-47 3 PREVALENCE of MORBIDITY • Cigarette smoking is the primary cause. Year Consultations 1980 6.1 million 1985 7.4 million 1990 10.1 million 1995 11.8 million 2000 13.9 million 2025 ↑↑ 1.6 billion • WHO estimates 1.1 Billion smokers in world. • In India 1,49,00,000 chronic cases of COPD in the age group of ? 4 30 4000 chemicals (more than 60 carcinogens) are inhaled in cigarette smoke Currently there are 94 million smokers in India COLLEGE STUDENTS ( 2%) TENDER AGE GROUPS Every day 55000 Indian youth start tobacco use Dr.Sarma@works 6 THE NUMBER OF WOMEN SMOKERS& PASSIVE SMOKERS IS ON RISE Risk Factors for COPD Nutrition Infections Socio-economic status Genes (alpha1- anti-trypsin↓) Aging Populations 7 TYPES OF COPD Simple concept……. CHRONIC BRONCHITIS COPD 1. Mucus gland hypertrophy 2. Smooth muscle hypertrophy 3. Goblet cell hyperplasia 4. Inflammatory infiltrate Normal bronchial architecture Dr.Sarma@works 5. Excessive mucus 10 6. Squamous metaplasia PULMONARY VASCULAR CHANGES IN COPD Normal Pulmonary Artery 1. THICK VESSEL WALL 2. INFALMMATORY CELLS INFILTRATE 3. COLLAGEN DEPOSIT 4. DESTRUCTION OF CAPILLARY BED 4 Dr.Sarma@works 14 3 COPD Pathophysiology Fig. 29-7 Did you know? • The King of Pop suffered from Alpha-1 antitrypsin deficiency, Centrilobular (central part of lobule) •Dilation and destruction of respiratory bronchioles and pulmonary capillary bed •Prominent in upper lobes Panlobular (destruction of whole lobule) •Affects respiratory bronchioles, alveolar ducts, and alveolar sacs. •Prominent in lower lobes Clinical Manifestations • Develops slowly around 50 yrs of age after 20 pack years of cigarette smoking * Packets per day x Years of smoking = Pack Years • Diagnosis is considered with – Cough – Sputum production – Dyspnea – Exposure to risk factors Clinical Manifestations • Intermittent Cough with expectoration • Progressive Dyspnea Described by the patient as an “increased effort to breathe,” “heaviness,” “air hunger,” or “gasping.” Clinical Manifestations • chest breathing – Use of accessory such as those in the neck and intercostal muscles – Decreased abdominal breathing – flattened diaphragm from over distended lungs. – Purse lip breathing on expiration. It helps to prevent airway collapse by increasing pressure . Clinical Manifestations • Barrel Chest• Air gets trapped causing increase in antero posterior dimensions of the chest • Characteristically underweight with adequate caloric intake • Chronic fatigue COPD Clinical Manifestations • Tripod position • Patient may sit upright with arms supported on a fixed Surface .This optimises the function of pectoral muscles to expand thoracic cavity. • Bluish-red color of skin – Polycythemia and cyanosis • Hemoptysis •Poor ventilation and perfusion; unable to compensate leading to hypoxia and cyanosis •Clubbing •Over ventilate to maintain relatively normal ABG’s •Red face DIAGNOSTIC EVALUATION • • • • • • • *Percussion : Hyperresonant depressed diaphragm, *Auscultation: Prolonged expiration ; reduced breath sounds; The presence of wheezing during quiet breathing Crackle can be heard if infection exist. • The heart sounds are best heard over the xiphoid area. Para clinical examination • CT: highlighting the pulmonary emphysema and emphysema bubbles. • Blood examination In excerbation or acute infection in airway, leucocytosis may be detected. • Screening for alpha 1 antitrypsin deficiency • Sputum examination streptococcus pneumonia Haemophilus influenzae klebsiella pneumonia • 6-Minute walk test to determine O2 desaturation in the blood with exercise • ECG can show signs of right ventricular failure • ABG typical findings – Low PaO2 – ↑ PaCO2 – ↓ pH – ↑ Bicarbonate level found in late stages COPD Spirometry • FEV1 – Forced expired volume in the first second • FVC – Total volume of air that can be exhaled from maximal inhalation to maximal exhalation • FEV1/FVC% - The ratio of FEV1 to FVC, expressed as a percentage. SPIROMETRY NORMAL AND COPD 0 FEV1 N o rm a l COPD 1 L iter 2 FVC F E V 1/ F V C 4 .1 5 0 5 .2 0 0 80 % 2 .3 5 0 3 .9 0 0 60 % FEV1 3 COPD FVC 4 FEV1 N o rm a l 5 1 Dr.Sarma@works 2 FVC 4 3 29 5 6 S e c o nd s CHEST SKIAGRAMS EMPHYSEMA Dr.Sarma@works 30 OF V- P MISMATCH NUCLEOTIDE IMAGING Dr.Sarma@works 31 HRCT – NORMAL CHEST Dr.Sarma@works 32 HRCT – EMPHYSEMA Dr.Sarma@works 33 Management based on GOLD Post-bronchodilator FEV1 (% predicted) NO TOMORROW! 1. Assess and monitor disease 2. Reduce risk factors 3. Manage stable COPD 4. Education 5. Pharmacologic IF ONE QUITS SMOKING 1. Studies have shown that with smoking cessation • The rate of decline in lung function slows • There will be definite clinical improvement in symptoms 6. Non-pharmacologic 7. Manage exacerbations 37 REHABILITATION For the lungs to get more air PURSED-LIP BREATHING (like breathing out slowly into a straw) INHALE Dr.Sarma@works EXHALE 38 REHABILITATION For the lungs to get more air DIAPHRAGMATIC BREATHING 1. Sit comfortably and relax your shoulders. Sit comfortably and relax your shoulders Note: 2. Put one hand on your 3. Then push in your abdomen. Now inhale abdominal muscles and slowly through your breathe out using the nose. (Push your pursed-lip technique. abdomen out while you (You should feel your Putbreathe one hand Then pushgoindown) your abdominal in)on your abdomen.abdomen Now inhale slowly through your muscles and breathe out nose. (Push your abdomen therest. pursed-lip technique • Repeat the above maneuver three times and thenout takeusing a little whilemany you breathe • This exercise can be done times ain) day. Dr.Sarma@works 39 Positions for Postural Drainage 41 Cupped-Hand Position 42 Flutter Mucus Clearance Device 43 Methods of Oxygen Administration C. Venturi Mask D. Tracheostomy Mask E. Face Tent F. Standard Nasal Cannulas Fig. 29-11 C-F 44 Simple Face Mask for Oxygen Administration Plastic Face Mask with Reservoir Bag for Oxygen Administration Fig. 29-1145A You administer high flow supplemental oxygen to a patient with COPD and the patient stops breathing. What Happened to your patient? The single most important driver of ventilation is CO2 But can be deadly for the COPD Patient CO2 CO2 CO2 CO2 CO2 CO2 Microsoft clipart CO2 You removed his drive to breathe! DIET PLAN Calories -1300 to 1800 Kcal/day Protein - 1 gm/kg/body weight Fat - 50 gm Fibers - 30 to 35 gms Potassium rich diet Salt 10 gm/day Hydration 3 litre /day SURGERY 1. LVRS - Lung volume reduction surgery 1. Single lung transplant 1. Bullectomy 51 COPD Complications • • • • • Cor pulmonale Exacerbations of COPD Acute respiratory failure Peptic ulcer disease Depression/anxiety Pathophysiology of Cor Pulmonale COPD Acute Respiratory Failure • Caused by – Exacerbations – Cor pulmonale • Discontinuing bronchodilator or corticosteroid medication – Overuse of sedatives, benzodiazepines, and opioids – Surgery or severe, painful illness involving chest or abdomen Peptic Ulcer Disease • Hyper secretion of gastric acid due to increased arterial co2 and decreased arterial o2. • Commonly in duodenum and painless • Depression may be four times more likely for COPD patients • Depression/Anxiety • Anxiety complicates – Respiratory compromise – Dyspnea – Hyperventilation NURSING DIAGNOSES • Impaired gas exchange related to ventilation perfusion mismatch • Ineffective breathing pattern related to bronchoconstriction. • Self care deficit (global) related to generalised weakness secondary to increased work of breathing • Sleep pattern disturbance related to breathing difficulty • Ineffective individual coping related to dyspnea, and hospitalisation. NURSING DIAGNOSES Contd….….. • Interrupted family process related to chronic condition. • Risk for aspiration related to depressed cough/ gag reflexs, impaired swallowing or delayed gastric emptying. • Risk for infection related to ineffective pulmonary clearance • Risk for impaired skin integrity related to prolonged bed ridden. • Anxiety related to outcome of disease • Deficient knowledge regarding self management to be performed at home. Assessment Nursing Objective Nursing intervention diagnosis Subjective data Patient verbalises that he has breathing difficulty Objective data confused, use of accessory muscles, restless Clinical findings Dyspnoea grade III, RR 26 /mtin, Auscultation: Wheeze both lung fields Documentary evidence ABG-Resp.acidosis pH <7.35 PaCo2>45mmHg PaO2<60 mm Hg SaO2<90% at rest 1. Help the patient to assume position of Impaired Maintains comfort -tripod position or head end gas optimum elevation with back rest- to maximise exchange gas respiratory excursion and to ease work of related to exchange breathing bronchial levels. obstruction , spasm and trapping Evaluation Improved mental status ,eupnoea, relaxed PaCo2of 352.Administer appropriate bronchodilators 45 mm Hg Pa O2as prescribed to open the airways normal 3.Administer oxygen as ordered through appropriate device to increase saturation 4.Plan rest and activities in such a way (pace out nursing / club procedures) to minimise tissue oxygen demands 5.Teach and demonstrate purse-lip breathing to prolong expiratory phase and to slow down the rate of respiration 6. Administer humidified oxygen and employ room humidification to mobilize secretions Nursing assessment Nursin g diagno sis Subjective data: Ineffect Patient verbalizes ive difficulty in breathing, breathi tiredness, not able to lie ng down flat and cough pattern Objective data: related Dyspnoeic grade –, to shortness of breath, decreas frequent sighs, ed lung use of accessory expansi muscles of breathing, on nasal flaring, cough Clinical findings: RR -> 24 breaths /minute Irregular breathing rhythm Increased AP diameter of chest IE ratio 2:4 Documentary evidence Respiratory acidosis Chest skiagram Consolidation of both lower lobes of lungs Goal Nursing interventions Main tain effect ive breat hing patte rn 1. Position patient in a semi to high Fowler’s position to promote maximum diaphragmatic descent and lung expansion. 2. Use additional pillows as needed to prevent slumping because slumping causes the abdominal contents to be pushed up against the diaphragm and restrict lung expansion. 3. Provide uninterrupted rest periods to increase strength and activity tolerance which in turn promotes participation in activities to improve breathing pattern. 4. Instruct patient to do deep breathing exercise as follows. a.)Sit up, stand or lean forward slightly while sitting on edge of bed or chair.b.)Take in a slow, deep breath c.)Pause slightly or hold breath for at least 3 secs. d.)Exhale slowlye.)Rest and repeat as tolerated. 5. Instruct patient to do pursed-lip breathing as it causes a mild resistance to exhalation, which creates positive pressure in the airways. This pressure helps prevent airway collapse and subsequently promotes more complete alveolar emptying Evaluation Patient verbalized less breathing difficulty Patient will maintain normal respiratory rate Regular breathing rhythm Reduction in cough No use of accessory muscles for breathing IE ratio 1:2 Normal and Spo2 > 95 % Assessment Nursing diagnosis Objectiv Nursing intervention e Subjective data: Patient verbalizes that I am not able to perform daily activities Self care deficit global (Feeding, toileting, bathing, grooming) related to lack of coordinatio n, muscular weakness Resume s self care activitie s Objective data: Patient is unable to perform ADL Clinical findings: Limited ROM Muscle powerreduced ADL scale-0/5 Documentary evidence: BP-140/90 mm Hg PR-90/min RR-20/min Evaluation Patient will verbalizes that his self care activities are resumed. Patient is able 2. Encourage the patient to brush his teeth, to perform comb the hair, bathe and feed himself and activities of to assist in toileting to promote the self care daily living. 1. Approach patient from his unaffected side and arrange call light beside table, helps the patient to compensate for alteration in sensory perception. activities. ROM, 3. Perform back massage by following 5 Muscle steps to prevent the occurrence of bedsore. power, ADL scoreincreased. 4. Help the patient to resume most normal eating position (may sit on chair with pillow support) suited to the patient’s disability to ease the feeding. Assessment Nursi ng diagn osis High Subjective data risk for Objective data injury Confusion, relate Altered gait/mobility d to diminished cognitive altere process, d Unable to carry out senso self care activities, ry perce Clinical findings ption, Blood pressuredimin 140/70 mm Hg ished Visual field deficits menta Muscle strength l score- upper and status, lower limbs -1/5 Documented evidence Radioimaging studies reveals Consolidation of both the lower lobes of lung field, Goal Intervention Evaluatio n Help the patient to prevent from injury/ falls 1.Place articles within easy reach of the patient to prevent from chance of fall. 2.Orient the patient to surroundings in order to promote familiarity to the situation. 3.Teach the patient about the importance of wearing supportive shoes with good traction when ambulating because it provides better balance and protect from instability on uneven surfaces. 4.Ensure adequate lighting in all areas used by the patient. 5.Use side rails of appropriate height and length which decreases chance of fall from falls. 6.Involve family to aid with activities of daily living and prevent from falls. 7.Avoid use of restraints because they may increase agitation. 8.Provide safe environment which allows the patient to move about as freely as possible and relieves the family of constant worry of safety. 9.Educate the patient about certain medications that may Patient regains normal range of body Temp:99°F Pulse:98ea ts/min Resp:20br eaths/min Assessment Nursing diagnosis Goal/ Objective Nursing interventions Evaluation Subjective Risk for Prevent 1.Elevate the head of bed at least 30◦ during data: aspiratio the risk of feedings and for one hour after feeding to Experien ce no Patient n related aspiration prevent reflux by use of reverse gravity. verbalizes on to aspiratio 2.Instruct individual and family on activities n difficulty depresse as swallowing a d cough/ that increase intra abdominal pressure. evidence Objective gag Instruct on safety when feeding. d by data: reflexs, 3. Use appropriate measures to check the noiseless presence of impaired placement of nasogastric feeding tubes. respirati NG tube. swallowi Malplacement of nasogastric feeding tubes ons, Clinical ng or findings: delayed may result in aspiration of enteral formula. clear breath Decreased/ gastric absent gag emptying 4.Regulate gastric feedings using an sounds; reflex, . intermittent schedule, allowing periods for clear, Documentary stomach emptying between feeding intervals. odorless evidence: secretion th SpO2 90% with 5. Aspirate the contents every 4 hourly to s. 6L of O2. determine the amount of the residual volume. Assessment Nursin g diagno sis Goal Subjective Data Risk patient The patient for maintai verbalizes itching ns over the site/all imp aire intact, over the body. moist Objective Data d and Skin-moist colour skin wellSkin turgor Clinical findings inte lubricat - Presence of grity ed skin excoriation relat Dehydration ed (Stage-) - Chronic bed to ridden status prol (immobility) ong - Braden’s ed scale-15/25 - Documented bed ridde Evidence n, - Prolonged use of topical applicants Nursing interventions 1. Inspect the skin frequently for areas of redness, swelling . to detect early signs of infection 2. Provide meticulous skincare to the skin folds that overlap and places where moisture collects. (Abdomen folds, under and between breasts, between buttocks or perineum)to reduce the skin breakdown. 3. Reposition the patient Q2hrly to relieve pressure over bony prominences. 4. Use pressure-reliving devices such as air/water mattress, pillows etc. to promote comfort of the patient. 5.Clip patient’s nails short and keep clean to prevent excoriation 6. Avoid use of perfumed soaps, lotions, deodrants on involved skin surface to prevent skin excoriation. 7. Encourage use of super fatted soap to maintain the moisture content in the skin. 8. Decrease environmental irritants such as heat, scratchy coverings to reduce vasodilatation and sensory stimulation. 9. Encourage adequate fluid intake (2000-3000ml/day) to prevent dehydration. 10. Elevate edematous areas to promote venous drainage. Evaluation The patient mainta ins intact and well lubrica ted skin. Nursing Outcomes: • Respiratory Status: Ventilation - movement of air in and out of lungs • Respiratory Status: Airway Patency - open, clear tracheobronchial passages • Knowledge: Medications - extent of understanding conveyed about the safe use of medication All the best THANK YOU