Strictly Clinical —
Taking action against
acute COPD
By Mary Lou Warren, MSN, RN, CNS-CC, CCRN, and Sarah Livesay, BSN, RN
MOST NURSES, you’ve
Exacerbations are common associated largely with elderly
probably cared for many patients
populations, it’s increasingly
among the 14 million
with chronic obstructive pulprevalent among middle-aged
Americans with COPD. To
monary disease (COPD). This
adults.
umbrella term denotes a group
intervene effectively, you
of conditions—emphysema,
Risk factors and assessment
need up-to-date nursing
chronic bronchitis, and in some
Cigarette smoking is the leading
cases, asthma—associated with
COPD risk factor. Other risk facknowledge and expertise.
an abnormal inflammatory retors include exposure to occupasponse and severe pulmonary airflow obstruction. The
tional and environmental pollutants and childhood rescondition progresses slowly and isn’t fully reversible;
piratory infections. Alpha-1-antitrypsin deficiency is the
no known cure exists.
best documented genetic risk for developing COPD.
Many COPD patients experience acute exacerbations
This deficiency may predispose some persons to emrequiring emergency treatment and sometimes hospitalphysema and may be a factor in causing emphysema
ization. Tracheobronchial infection and air pollution are
in people who’ve never used tobacco or who develop
the most common causes of exacerbations, but about
the illness at an early age.
one-third of the time, the cause can’t be identified.
General signs and symptoms of COPD include
COPD accounts for about 1.5 million emergency decough, excessive mucus production, and shortness of
partment visits by adults ages 25 and older.
breath on exertion. During exacerbations, fever, puruA thorough understanding of COPD and its treatment
lent sputum, increased cough, and increased shortness
helps you provide the most effective patient care. Upof breath may occur. (For manifestations specific to
to-date knowledge of the disease and appropriate medemphysema or bronchitis, see Comparing emphysema
ical treatment and nursing interventions can improve
and bronchitis.)
patient outcomes and quality of life.
This article discusses management
of patients who’ve been hospitalized for acute COPD exacerbations.
LIKE
Comparing emphysema and bronchitis
More than 14 million people in the
United States have COPD. A leading
cause of chronic illness, disability,
and death, COPD resulted in 119,000
deaths and 726,000 hospitalizations
in 2000. The total cost of the disease
was estimated at $32 billion in 2002.
COPD is the fourth leading
cause of death in the United States
and is expected to become the
third leading cause by 2020. COPD
deaths have been increasing, while
deaths from coronary artery disease
and stroke have been declining.
COPD is now equally prevalent
in men and women. Although once
12 American Nurse Today
December 2006
Emphysema and bronchitis are the two main forms of chronic obstructive pulmonary
disease (COPD). A patient may have one or both conditions.
In emphysema, alveoli overinflate. As they undergo progressive damage, pockets of
dead air called bullae form, impeding exhalation. Signs and symptoms include shortness of breath on exertion and air hunger. Many emphysema patients develop a barrel
chest from lung hyperinflation.
Bronchitis is marked by inflammation of the tracheobronchial mucous membranes.
Abnormal bronchial changes impede bronchial drainage, increasing mucus production.
Bronchitis is considered chronic when symptoms last at least 3 consecutive months in
at least 2 consecutive years. Acute bronchitis is relatively common in COPD patients.
Assessment findings during an acute exacerbation
During an acute emphysema or bronchitis exacerbation, expect:
• breathlessness
• increased sputum
• wheezing
• change in sputum color
• chest tightness
• decreased activity tolerance
• increased cough
• general malaise and fatigue.
Photo: National Institutes of Health
The vast toll of COPD
Treating acute exacerbations
For patients hospitalized with acute
COPD, treatment may entail behavior therapy, pulmonary rehabilitation, medical or surgical interventions, and education. Medical
treatment is essential and may involve bronchodilators, inhaled glucocorticoids, oxygen therapy, and
antibiotics.
Bronchodilators
Bronchodilators improve symptoms
and functional status in COPD patients. They fall into two broad
categories:
• beta-agonists, which relax and
open the airways by causing
smooth-muscle relaxation
• anticholinergics, which block
acetylcholine (a chemical that
normally causes the airways to
contract) and decrease mucus
production. (See Bronchodilator
therapy for COPD patients.)
Exacerbations usually necessitate
an increased dosage or dosing frequency of the bronchodilator,
which may be given every 2 to 3
hours. Beta-agonists and anticholinergics also may be given to increase the bronchodilatory effect.
Drug delivery devices vary. To
provide education and assess the
patient’s ability to self-administer
the drug effectively, make sure
you’re familiar with the appropriate
delivery device.
Bronchodilator
therapy for COPD patients
Signs
and Symptoms of Hypoglycemia
S
For patients with chronic obstructive pulmonary disease (COPD), bronchodilator
therapy may involve fast- and long-acting beta-agonists or anticholinergics.
• Fast-acting agents have a faster onset and shorter duration. When used for symptom control, they must be given every 4 hours. They’re also indicated for “rescue”
treatment during an acute episode of shortness of breath or before increased activity. Most come in aerosol form and should be used with a spacer device.
• Long-acting agents can be given once or twice daily. They provide better and
longer symptom control and greater convenience. Typically, the active ingredient
is a powder for inhalation.
The COPD treatment plan usually includes a long-acting bronchodilator for
symptom control and a short-acting bronchodilator for “rescue” in acute situations.
Patients who have acute exacerbations typically are advised to increase the bronchodilator’s dosage or dosing frequency and to combine beta-agonists with anticholinergics for greater effect.
This chart lists specific bronchodilating drugs used to treat COPD, along with
their uses and corresponding nursing considerations.
Drug category
Uses and nursing considerations
Fast-acting beta-agonists
• albuterol
• pirbuterol
• Uses: to relax and open airways, increase
ciliary movement to help clear mucus,
and help prevent exercise-induced wheezing;
for “rescue” to help stop attacks
• Usually are given as two puffs every 4 hours
• Should be used with spacer device or in
nebulizer (albuterol)
Long-acting beta-agonists
• formoterol
• salmeterol
• Uses: to relax and open airways and for
long-term control
• Available as powder for inhalation
• Usually given as one inhalation twice daily
Fast-acting anticholinergics
• ipratroprium
• Uses: to relax and open airways
• Should be used with spacer device or in nebulizer
Long-acting anticholinergics
• tiotroprium
• Uses: to relax and open airways and for longterm control
• Available as powder for inhalation
• Usually given as one inhalation once daily
Glucocorticoids
Inhaled glucocorticoids are recommended for patients
with repeated exacerbations or whose forced expiratory
volume1 (FEV1 ) is less than 50% of the predicted value.
FEV1 is the volume of air forced out of the lungs in the
first second of exhalation after a maximal inspiration.
During an exacerbation, glucocorticoids initially may be
given I.V. and later switched to the oral form.
The dosage must be tapered before discontinuation.
Although no standard tapering protocol exists, a treatment course commonly spans 10 to 14 days.
Oxygen therapy
Long-term oxygen therapy increases survival in COPD
patients with chronic respiratory failure. Supplemental
oxygen improves hemodynamics, exercise endurance,
lung mechanics, and mental status.
During an exacerbation, oxygen therapy is adapted
to the patient’s condition. Obtain an arterial blood gas
sample to evaluate the patient’s arterial oxygenation,
carbon dioxide (CO2) level, and acid-base balance.
Oxygen delivery must be regulated to avoid increased
CO2 levels and acidosis.
As the patient stabilizes, measure room air oxygen
saturation (O2 Sat) before and after activity. If O2 Sat is
below 90% within 48 hours of the planned discharge,
the patient’s eligibility for home oxygen therapy should
be evaluated.
Antibiotic therapy
If your patient shows signs of bacterial infection, expect to administer oral or I.V. antibiotics. Signs and
December 2006
American Nurse Today
13
symptoms of bacterial infection
may include increased dyspnea,
sputum production, and sputum
purulence.
Vaccinations
To prevent exacerbations, COPD
patients should receive appropriate
vaccinations. Administering the influenza vaccine may reduce serious
illness and death by nearly 50%.
Behavior therapy
Behavioral therapy is a key component of COPD treatment. Smoking
cessation is the most effective way
to prevent COPD or slow its progression. Provide counseling regarding smoking cessation with
every hospitalization.
Pulmonary rehabilitation
Teaching patients how to use a flutter valve
A small, hand-held device that helps loosen and expel pulmonary secretions, the flutter
valve consists of a small plastic cone housing a steel ball. Exhalation forces the ball upward.
When the ball falls back toward the bottom of the device, its movement causes vibrations
and increased pressure, in turn helping to loosen pulmonary secretions.
When providing instructions on flutter valve use, teach the patient to inhale deeply,
hold the breath for 2 to 3 seconds, and then exhale into the flutter valve. Advise him to use
the valve up to four times daily, with 10 to 15 repetitions per session. If he’s using a prescribed bronchodilator, instruct him to use the drug before the flutter valve to help mobilize secretions.
Breathing techniques for COPD patients
Shortness of breath results from trapped, stale air. In patients with chronic obstructive pulmonary disease (COPD), clogged, narrow airways or damaged alveoli exacerbate air trapping. As part of pulmonary rehabilitation, patients typically are taught special breathing
techniques, such as pursed-lip breathing and diaphragmatic breathing, that reduce air
trapping and bring other respiratory benefits.
Pulmonary rehabilitation programs
Pursed-lip breathing
are designed to optimize the paPursed-lip breathing improves ventilation by promoting movement of old air out of the
tient’s physical and social performlungs and increasing airway pressure, which helps keep the airway open. As exhalations
ance. Goals include improving
lengthen, the respiratory rate slows and the work of breathing declines, in turn relieving
physical endurance and respiratory
shortness of breath and causing general relaxation.
muscle strength, easing symptoms,
To teach your patient how to perform pursed-lip breathing, demonstrate the following
and improving quality of life.
steps and request a return demonstration:
Tailored to each patient, these
1. Relax your shoulders and neck muscles.
2. Close your mouth and inhale slowly through your nose, as if you’re smelling roses.
multidisciplinary programs teach
3. Purse your lips as if blowing out a candle.
COPD patients about the disease
4. Exhale slowly through your lips, as if blowing out a candle, for at least a count of three.
process, self-care, exercise, medications, and proper nutrition. They
Diaphragmatic breathing
focus on lower and upper extremiDiaphragmatic breathing strengthens the diaphragm and decreases the respiratory rate
ty exercise and conditioning,
and oxygen demand. As a result, the overall work of breathing eases. To teach diaphragbreathing retraining, education, and
matic breathing, demonstrate the following steps and request a return demonstration:
psychosocial support.
1. Relax your shoulders and neck muscles.
In hospital settings, pulmonary
2. Place your hands on your abdomen.
3. Inhale slowly through your nose and relax your stomach muscles. As you do this, feel
rehabilitation typically involves the
your abdomen move against your hands.
use of special breathing techniques,
4.
Exhale slowly though your pursed lips as you tighten your abdominal muscles. Feel
a flutter valve, and incentive spiyour abdomen move away from your hands as you exhale.
rometry to mobilize pulmonary
secretions and improve respiratory
effort. (See Breathing techniques for COPD patients and • lung volume reduction surgery (removal of certain
Teaching patients how to use a flutter valve.)
lung portions)
Before discharge from an acute-care setting, the pa• lung transplantation.
tient should be evaluated for eligibility for outpatient
pulmonary rehabilitation.
Ventilatory support
Although ventilatory support hasn’t been proven effecSurgical treatment
tive in routine management of stable COPD, evidence
Reserved for patients with severe COPD, surgery may
suggests noninvasive mechanical ventilation helps durinvolve:
ing acute exacerbations in patients with hypercapnea
• bullectomy (removal of distended, nonfunctional
(elevated CO2 and blood pH below 7.35). This type of
pulmonary air spaces)
ventilation reduces the work of breathing, improves
14 American Nurse Today
December 2006
ventilation, decreases the respiratory
rate, increases tidal volume, boosts
oxygenation, reduces acidosis, and
decreases mortality rates. Expected
patient outcomes include decreased
length of stay in the intensive care
unit and decreased incidence of
infection.
Noninvasive ventilation is delivered by a nasal or face mask—usually in the form of bilevel positive
airway pressure (BIPAP) or continuous positive airway pressure (CPAP).
• BIPAP provides continuous highflow positive pressure, which cycles between high positive pressure
during inhalation and lower positive pressure during exhalation.
• CPAP provides continuous highflow positive pressure set at a
constant pressure.
As the underlying condition improves, use of the ventilation device
is decreased. Once the patient’s condition stabilizes, ventilatory support
is discontinued.
Patients who need ventilatory assistance but don’t respond to noninvasive mechanical ventilation may
require intubation.
Supporting your patient as
COPD progresses
Despite high-quality care, COPD patients gradually progress toward the
end stages of the disease. Over time,
they may require more frequent
hospital stays and may have shorter
intervals between exacerbations.
Yet, despite this inevitable decline,
your expertise and knowledge regarding COPD assessment and management can enhance your patient’s
survival and improve quality of life.
Inform patients that with proper care,
the disease can be managed and its
progress can be slowed. Provide
emotional support to the patient and
family and, as appropriate, refer them
for counseling.
✯
Selected references
American Thoracic Society. ATS statement:
pulmonary rehabilitation—1999. Am J Respir
Crit Care Med. 1999:159:1673.
Braman, S. Update on the ATS guidelines for
COPD. Medscape Pulmonary Medicine. 2005;
9(1). Available at: www.medscape.com/
viewarticle/498648. Accessed October 14, 2006.
Global Initiative for Chronic Obstructive
Lung Disease (GOLD). Global strategy for
the diagnosis, management, and prevention
of COPD; GOLD executive summary (2005
update). Available at: www.goldcopd.com/
Guidelineitem.asp?l1=2&l2=1&intId=996. Accessed September 28, 2006.
Huang M, Singer LG. Surgical interventions
for COPD. Geriatrics Aging. 2005;8(3):40-46.
National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2004 Chartbook on Cardiovascular, Lung, and Blood Diseases. Available at: www.nhlbi.nih.gov/resources/docs/
cht-book.htm. Accessed September 28, 2006.
Mary Lou Warren, MSN, RN, CNS-CC, CCRN, is a
Clinical Nurse Specialist in the Intensive Care Unit at
MD Anderson Cancer Center in Houston, Tex. Sarah
Livesay, BSN, RN, is Neuroscience Outcomes Manager
at St. Luke’s Episcopal Hospital in Houston.
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