Respiratory Module
C.O.P.D.
COPD - overview
COPD?
–
•
COLD?
–
•
Chronic Obstructive Pulmonary Disease
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 + h secretion of mucus 
• h goblet cells +
• h mucus secreting glands + h Mucus
• i 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. Spring
C. Summer
D. 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
– h dead space
– Impaired passive expiration
•  Impaired gas exchange
Emphysema
• Impaired gas exchange
– impaired expiration
•
•
•
•
Hypoxemia
h CO2 
Hypercapnia
Respiratory acidosis
Emphysema
• Damaged pulmonary capillary bed
– h pulmonary pressure 
– h 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. Cough
2. Sputum production
3. Dyspnea on exertion
(Secondary)
•
•
•
Wt. loss
Resp. infections
Barrel chest
C.O.P.D.
Nrs. Assessment
•
•
•
•
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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
• i
– Functional residual
• h
– Spirometry / FEV (force of expired vol.)
• i
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
• Corticosteriods
Secondary
• 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 Flashback
Which of the following is an iatrogenic event
secondary to prolonged use of corticosteroid
medications?
A. SIADH
B. Diabetes Insipidus
C. Cushing disease
D. Addison’s disease
E. Acromegaly
What electrolyte imbalance is assoc with
Cushing Syndrome?
A.
B.
C.
D.
E.
F.
Hypercalcemia
Hypocalcemia
Hypernatremia
Hyponatremia
Hyperkalemia
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
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•
•
•
•
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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
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–
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–
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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
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(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
•  h 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 &
h mucus production leads to
• Recurrent episodes of symptoms
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–
–
–
Cough
Chest tightness
Wheezing
dyspnea
Asthma
What is the strongest predisposing factor for
asthma?
A. Smoking
B. Family history
C. Allergy
D. Having a weird middle name
Asthma
Pathophysiology
• Mast-cells play a key role in the inflammatory
process
• Alpha– adrenergic receptors trigger bronchoconstriction
What is the action of a
mast-cell stabilizer
A. Reduces histamine release
B. Increases the effectiveness of the white
blood cells
C. Increase WBC production
D. Bronchodilatation
Thought question?
Why is Asthma not considered a form of
C.O.P.D?
A. Smoking is not a risk factor
B. It is not irreversible
C. It doesn’t start with the letter “C”
D. It is not a chronic disease
E. It is not an obstructive disease
Asthma
S&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!
Asthma
Prevention
• Manipulate known
triggers
– Stress
– Pollen
• Exercise
Asthma
Rx therapy
2 general classes of asthma medications
1. Quick-relief
2. Long-acting
• Because of the underlying pathology of asthma is
inflammation, controlled primarily with antiinflammatory meds
Asthma
Rx 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.
B.
C.
D.
ARDS
Asthma
Chronic obstructive bronchitis
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. Asthma
B. Chronic Bronchitis
C. 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 vaccines
B. These vaccines produce bronchodilation and
improve oxygenation
C. 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.
B.
C.
D.
It enhances cardiovascular fitness
It improves respiratory muscle strength
It reduces the number of acute attacks
It worsens respiratory function and is
discouraged
Clients with Chronic Obstructive Bronchitis
are given diuretics. Which of the following
best explains why?
A.
B.
C.
D.
Reducing fluid volume reduces oxygen demand
Reducing fluid volume improves the clients mobility
Reducing fluid volume reduces sputum production
Reducing fluid volume improves respiratory function