Chronic Obstructive Pulmonary Disease (COPD)

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BCCC 102 med surg

Chronic Obstructive Pulmonary Disease (COPD)

disease state characterized by the presence of airflow obstruction caused by chronic bronchitis or emphysema

Primary cause of COPD

Cigarette smoking

Effects of Cigarette Smoking

irritating effects on the respiratory tract
reduces ciliary activity and can cause loss of ciliated cells
produces abnormal dilation of distal air spaces w/ destruction of alveolar walls

Most common causative organisms (infection)

Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis

Causes

Cigarette smoking
Ambient Air Pollution
Heredity <1% of cases in U.S
Aging

Aging

lung structure (become more rounded and smaller)
thoracic cage (becomes stiff and rigid)
respiratory muscles and the number of functional alveoli decreases
gradual loss of elastic recoil in lungs

Emphysema

abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls

Emphysema Structural Changes

hyperinflation of alveoli, destruction of alveolar walls and capillary walls, narrowed and small airways, and loss of lung elasticity

2 major types of emphysema

Centrilobular and Panlobular

Centrilobular

the primary area of involvement is the central part of the lobule. Chronic bronchitis is often associated with this kind

Panlobular

(less common) involves distention and destruction of the whole lobule

Clinical Manifestations of Emphysema

Dyspnea which becomes progressively worse and more severe
DOE (dyspnea on exertion) progresses to interfering w/ ADLs (activities of daily living) to dyspnea at rest
Minimal coughing w/ NO sputum
Flattened diaphragm and barrel chest

Physical Manifstations of Emphysema

Thin and underweight even with adequate calorie intake (may be do to hypermetabolism or increased work of breathing)
Loss of lean muscle mass and subcutaneous fat
Advanced stages shows finger clubbing

Chronic Bronchitis

Excessive production of mucus in the bronchi accompanied by a recurrent cough that lasts for at least 3 months of the year during at least 2 successive years

Chronic Bronchitis Pathological changes

hyperplasia of mucous secreting glands in the trachea and bronchi, increase in goblet cells, disappearance of cilia, chronic inflammatory changes and narrowing of small airway, altered function of alveolar macrophages leading to increased bronchial infections (frequently airways are colonized w/ microorganisms

Clinical Manifestations of Chronic Bronchitis

frequent productive cough mostly during winter months and exacerbated by respiratory irritants and cold, damp air
Frequent respiratory infections
DOE (dyspnea on exertion)
H/O (history of) cigarette smoking
Hypoxemia and hypercapnia from hypoventilation caused by increased airway resistance
Hemoglobin 20 g/dl or >

Physical Manifstations of Chronic Bronchitis

Bluish-red color of the skin from polycythemia (increased RDC production as body tries to compensate) and cyanosis
Usually normal weight or heavyset

Cor Pulmonale

hypertrophy of the right side of the heart with or w/o heart failure resulting from pulmonary hypertension (caused by constriction of the pulmonary vessels in response to alveolar hypoxia)

pulmonary hypertension

pressure on the right side of the heart must increase to push blood into the lungs (eventually right sided heart failure develops)

Cor Pulmonale S/S

ECG (elecrocardiogram) changes, neck vein distention, hepatomegaly (enlarged liver) w. right upper quadrant tenderness, ascites (fliud in the peritoneal cavity), epigastric distress, peripheral edema and weight gain

Cor Pulmonale Management

low-flow O2 therapy, salt restriction, and diuretics

Acute Exacerbations of Chronic Bronchitis

acute infection - mucous which is stagnant and breeds microorganisms
worsened cough, hemoptysis (coughing up of blood), wheezing, increased SOB, changes in amount, color, consistency, or viscosity of sputum

Chronic Bronchitis Treatment

antibiotics, increase of bronchodialtor usage, corticosteroids, humidification, postural drainage

Acute Respiratory Failure

Usually an acute resp. infection or acute bronchitis leads to this

Hypercapnia

increased (CO2) in the blood

COPD O2 treatment

low flow rates of O2 and careful monitoring of ABGs (Arterial Blood Gas)

PUD (Peptic Ulcer Disease)

increased in the person w/ COPD but the reason is unknown

GERD (Gastro-esophageal Reflux Disease)

frequently in COPD patients and may aggravate respiratory symptoms (may be precipitated by COPD meds)

Pneumonia

Frequent complication of COPD
Most common causative agents are; S. pneumoniae, H. influenzae and viruses
Common manifestation is purulent sputum, maybe fever and chills

Respiratory Acidosis

retained CO2 results in accumulation of carbonic acid in the blood causing a decrease in pH

Bicarbonate HCO3 (normal)

22‐26 mEq

pH (normal)

7.35 - 7.45

PaCO2 (normal)

35-45 mm Hg

Respiratory Acidosis Uncompensated

pH low - PCO2 high - HCO3ok

Respiratory Acidosis Partial compensation

pH low - PCO2 high - HCO3 high

Respiratory Acidosis Compansated

pH ok - PCO2 high - HCO3 high

R O M E

respiratory opposite, metabolic equal

Who's the boss?

pH

PCO2

represents acid

HCO3

represents alkaline

Respiratory Alkalosis Uncompensated

pH high - PCO2 low - HCO3 ok

Respiratory Alkalosis Partial compensation

pH high - PCO2 low - HCO3 low

Respiratory Alkalosis Compansated

pH ok - PCO2 low - HCO3 low

Metabolic Acidosis Uncompensated

pH low - PCO2 ok - HCO3 low

Metabolic Acidosis Partial compensation

pH low - PCO2 low - HCO3 low

Metabolic Acidosis Compansated

pH ok - PCO2 low - HCO3 low

Metabolic Alkalosis Uncompensated

pH high - PCO2 ok - HCO3 high

Metabolic Alkalosis Partial compensation

pH high - PCO2 high - HCO3 low

Metabolic Alkalosis Compansated

pH ok - PCO2 high - HCO3 high

Diagnostic Studies for COPD

Health history and physical examination
Chest x-ray
Pulmonary function tests
Sputum specimen and culture
ABG
ECG
Exercise testing w/ oximetry
Echocardiogram or cardiac nuclear scan if needed

COPD Therapy

Breathing exercises and retraining
Hydration (3L/day)
Smoking cessation
Appropriate rest periods
Education
Flu vaccine
Low flow O2
Pulmonary rehab
Chest PT

COPD medications

Bronchodilator therapy: B-Adrenergic Agonist drugs (Proventil, Ventolin), Anticholenergic agents (Atrovent), Theophylline
Corticosteriods

Beta blockers treat

a variety of conditions, such as high blood pressure, glaucoma and migraines (ex. Tenormin, Coreg, Lopressor)

?Why not use beta blockers for COPD patients?

They reduce heart rate; reduce blood pressure by dilating blood vessels; and may constrict air passages by stimulating the muscles that surround the air passages to contract (possibility of worsening respiratory function from the potential side effect of bronchoconstriction)

Oxygen Delivery Systems Two categories

High flow O2 systems and Low flow O2 systems

low flow system

the % of oxygen delivered is determined by the person's rate, volume and pattern

high flow system

provides a flow rate and reservoir capacity to meet total inspired air needs

COPD O2 rate

provide the lowest % O2 that will maintain arterial O2 saturation within normal range

Low-flow Systems Include

nasal cannula, oxygen mask, or oxygen mask with reservoir

nasal cannula

most comfortable and most commonly used (it doesn't interfere w/ talking, eating, and can even be used w/ a mouth breather)

simple face mask

shaped to fit snugly over the nose and mouth. The sides have holes so exhaled CO2 can escape and O2 is mixed w/ room air. This is used when client needs a higher FIO2 (frational concentration of inspired oxygen) than provided by nasal cannula

non-rebreather mask

highest FIO2 (frational concentration of inspired oxygen). The bag fills w/ 100% O2. The air holes have a 1 way valve to allow exhaled air to escape and does not allow room air to enter
Do not let the bag get deflated or else the client will suffocate

Partial rebreathing mask

> in FIO2 (frational concentration of inspired oxygen) than the simple face mask but < in FIO2 than non-rebreather. Limited usefulness

Venturi device

beneficial in treating a client with chronic respiratory disease. Small amounts of O2 can be delivered very precisely (High-flow System)

Humidification of O2

prevent irritation and drying of the airways

Bubble diffusion humidifiers

Used w/ O2 (O2 is bubbled through H2O)
Use if O2 is needed more than 24 hours

Complications of Oxygen Use

Combustion, Carbon Dioxide Narcosis, Oxygen Toxicity

Combustion

No smoking unless you want to blow up. Signs should be placed around patient use area

Carbon Dioxide Narcosis

Sometimes increasing the rate of O2 can cause respiratory distress

Oxygen Toxicity

Monitor ABGs to avoid this. It can result from prolonged exposure to O2

Severe Hyperoxia

caused by breathing oxygen at elevated partial pressures. The high concentration of oxygen damages cells.

Pursed-lip breathing

The purpose is to prolong exhalation and prevent bronchiolar collapse and air trapping

Diaphragmatic breathing

focuses on using the diaphragm instead of the accessory muscles to achieve maximum inhalation and slow the respiratory rate

Chest Physiotherapy Includes

percussion, vibration, and postural drainage

Percussion

Use a cup-like position of the hands, fingers and thumbs are closed. Whack the patient and a hollow sound should be heard

Vibration - can be manual or machine. This again facilitates secretions upwards to be cleared

can be manual or machine. Facilitates secretions upwards to be cleared

Postural drainage

Positions which facilitate the upward movement of secretions. Sometimes bronchodilators are used prior

Ambulate

this increases rate and depth of breathing, opens the alveoli and distributes airflow through the lungs

Incentive Spirometry

a device that provides a visual goal encouraging the client to execute and sustain maximal inspiration. Opens airways, reduces actelectasis, stimulates coughing. Have client breath in deeply, hold for 3 seconds then exhale. Used frequently post-op

Pulmonary Rehabilitation

include; PT, nutrition and education

Activity considerations

energy conservation by spacing activities and allowing sufficient rest periods (modify sex routine, get adequate sleep)

Tracheostomy

A surgically created opening into trachea to establish an airway

Tracheostomy reasons for

To bypass an upper airway obstruction
Facilitate removal of secretions
Permit long-term mechanical ventilation
Permit oral intake and speech in a pt who requires mechanical ventilation

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