COPD

DEFINITION:-

 COPD is the progressive and partially reversible disease of the airway  Comprises primarily of two related disease- chronic bronchitis and Emphysema  Chronic obstruction of the flow of air through the airway and out of the lungs permanent and progressive obstruction over time.

Chronic bronchitis is defined clinically as a daily cough with production of sputum at least 3 month per year for 2 or more consecutive year.  It involves inflammation and swelling of the lining of the air way that leads to narrowing and obstruction of the air way.  The inflammation also stimulate production of mucus which can cause further obstruction of the airway. 

EMPHYSEMA  It is permanent enlargement of the alveoli due to destruction of the wall between alveoli which leads to reduce the elasticity of the lungs over all.  Loss of elasticity leads to collapse of the bronchioles, obstructing air flow out of the alveoli. Air become trapped to the alveoli and reduce the ability of the lungs to shrink during exhalation .

ETIOLOGY AND RISK FACTORS 

The specific causes of COPD are not clearly understood.

Some risk factors are

1.Cigarette smoking - The primary cause is exposure to tobacco smoke. cigarette smoking will develops COPD in 15% .Overall, tobacco smoking accounts for as much as 90% of the risk of COPD . 

Secondhand smoke

Secondhand smoke, or environmental tobacco smoke, increases the risk of respiratory infections.

2.Air Pollution  outdoor air pollution contributes to the development of COPD.  most common cause is indoor stoves for cooking  Some occupational pollutants such as cadmium and silica-

3.Alpha-1 Antitrypsin (AAT) deficiency-  AAT enzyme is produced by liver and present in normal lungs. Normal1.5-3.5 g/l. Block the damaging effects of elastase on elastin.

4. Chronic Respiratory Infections

5. Alcohol Ingestion

PATHOPHYSIOLOGY

Chronic inflammation Increase number of goblet cell and mucus secreation

Increase size and number of submucus gland in bronchi and mucus production

Decrease cillary function reduce mucus clearance (deposit )mucus

Allergic reaction IgE stimulation IgE attached to the mast cell

Mast cell release histamine and prostagladin

Mucus secretion

 bronchospasm

Bronchi constriction

Obstructive air way

SIGN AND SYMPTOMS 

• Cough, with or without mucus 

• Chronic cough and sputum production (in chronic bronchitis 

•Shortness of breath (dyspnea) that gets worse with mild activity  Trouble catching one's breath 

•Fatigue 

•Wheezing 

•Rhonchi,

•decreased intensity of breath sounds, and prolonged expiration on physical examination 

•chest tightness and tiredness 

People with advanced COPD sometimes develop respiratory failure

INVESTIGATION 

• Medical History 

• Physical examination finds enlarged chest cavity and wheezing.

• Blood Test  A hematocrit value of more than 52% in males and more than 47% in female indicates disease.  Measure the alpha1-antitrypsin (AAT),the AAT level is low

•Sputum for culture and microscopic examination mucoid sputum .  The pathogens Streptococcus pneumoniae and Haemophilus influenzae

• Chest X-ray-  Hyper inflated lung  Flat diaphragm  Tubular heart  Increase broncho vascular markings

severe bullous

 • High Resolution CT scanning(HRCT): is highly specific for diagnosing emphysema, and the outlined bullae are not always visible on a radiograph.  CT scan (COPD)  Two-dimensional echocardiography may be helpful as a screening tool to estimate pulmonary arterial systolic pressure and right ventricular systolic function.

•Pulmonary Function Test 

•Arterial blood gas analysis:  

 

COMPLICATIONS OF COPD 

•Respiratory Infections 

•Acute Respiratory Failure 

•Spontaneous Pneumothorax due to rupture of emphysematous bleb. 

•Ventilation Perfusion Mismatch 

•Hypoxemia 

•Corpulmonale

Medical management

The treatment goal for the client with COPD is 

•To improve ventilation 

•To facilitate the removal of bronchial secretions 

•To prevent complications 

•To slow the progression of clinical manifestations 

•To promote health maintenance and client management of disease.

Treatment strategies include 

•Quitting cigarette smoking 

 •Taking medications to dilate airways( bronchodilators) 

•Vaccinating against flu influenza and pneumonia 

•Regular oxygen supplementation

 •Pulmonary rehabilitation

MEDICAL MANAGEMENT 

 Quitting cigarette smoking: most important treatments for COPD.  Patients who continue to smoke have a more rapid deterioration in lung function when compared to others who quit.  If one stops smoking, the decline in lung function eventually reverts to that of a non- smoker

•Bronchodilators:

Beta2 agonists are the most frequently prescribed. (albuterol or salbutamol, metaproterenol) have minimal adverse effects, rapid onset of action 

Anticholinergic : bronchodilators work by blocking the cholinergic receptors resulting in bronchodilatation.( Atrovent) is the most commonly used drug in this category.  Methylxanthines(theophylline, aminophylline) are also used to treat acute exacerbations.

It is helpful for the patient with COPD who have heart failure and pulmonary hypertension. 

Corticosteroids are used in the acute management of clients with COPD exacerbations  Inhaled corticosteroids like Beclomethasone diproprionate, salmeterol and fluticasone are used.

 Regular oxygen therapy: Regular oxygen therapy is required when the client has severe exertion or resting hypoxemia (pao2 < 40mm of Hg). Oxygen (1-3L) by nasal canula may be required to raise the pao2 to no less than 60mm of Hg. (normal 80-100 mm of Hg)

 Postural drainage and chest physiotherapy they can be help expelled secretion.  Control complications: Edema and corpulmonale are treated with diuretics and digitalis.  Phlebotomy also reduces cardiac workload.

 Antibiotic- Treat with antibiotic therapy for recurrent bacterial infection.

 Promote exercise-

Aerobic exercise :Exercise does not improve lung function more effectively but strengthen the respiratory muscles even the lungs are diseased. 

 Progressively increased walking is the most common form of exercise. 

Encourage diaphragmatic breathing

 pursed-lip breathing.

Improve general health-

The most effective way to slow disease progression is for the client  to

•stop smoking 

 •avoid exposure to known allergens  •avoid high altitudes 

•Use supplemental O2 for air travel.  •Adequate nutrition is essential to maintain respiratory muscle strength.

•Regular O2 therapy should be maintained.

Nursing Management

1. Assess the client status ask detail about smoking (pack per year history), occupational exposure history, positive family history of respiratory disease etc.)

 2. Note amount, color and consistency of sputum.

3. The nurse should be inspect for use of accessory muscles during respiration and use of abdominal muscles during expirations.

4. The nurse plays a key role in identifying potential candidates for pulmonary rehabilitation and in facilitating and reinforcing the material learned in the rehabilitation program.

5. The nurse should teach to patient and family as well as facilitating specific services for the patient (e.g., respiratory therapy education, physical therapy for exercise and breathing retraining, occupational therapy, medications using e.g. MDI, Nebulization for conserving energy during activities of daily living, and nutritional counseling)

PATIENT EDUCATION •

Patient education is a major component of pulmonary rehabilitation and includes a broad variety of topics.

 • topics may include normal anatomy and physiology of the lung, pathophysiology and changes with COPD, medications and home oxygen therapy, nutrition, respiratory therapy treatments, symptom alleviation, smoking.

Breathing Exercise

Inspiratory muscle training is defined as a course of therapy consisting of a series of breathing exercises that aim to strengthen the bodies' respiratory muscles making it easier for people to breathe. Inspiratory muscle training is normally aimed at people who suffer from asthma, bronchitis, emphysema and COPD

• Self-Care Activities.

As gas exchange, airway clearance, & the breathing pattern improve, the patient is encouraged to assume increasing participation in self-care activities.

Oxygen Therapy

 Oxygen supplied to the home comes in compressed gas, liquid, or concentrator systems. Portable oxygen systems allow the patient to exercise, work, and travel.

Nutritional Therapy

Nutritional assessment and counseling are important aspects in the rehabilitation process for the patient with COPD.

Nursing diagnosis

1. Impaired  gas exchange related to dyspnoea, mucus plug and decreased ventilation

Goal: Client will be demonstrated improved ventilation and adequate oxygenation .

Nursing intervention 

Assess respiratory rate, depth, note use of accessory muscles, pursed lip breathing, inability to speak.

•Elevate head  of bed,

•assist patient to assume position to ease work of breathing.  •Encourage deep slow or pursed lip breathing as individually tolerated.  •Administer low- flow oxygen therapy (1-2lit/min) as needed via nasal prongs. 

•Administer bronchodilators if ordered 

• Regularly monitor the client's respiratory rate and pattern, pulse oximetry, ABG results.

2.Nursing Diagnosis: Activity  intolerance related to inadequate oxygenation and dyspnea 

Nursing Goals: The client will have improved activity tolerance within hospitalization period

Nursing Intervention  Monitor  the severity of dyspnea and oxygen saturation with and following activity 

•Keep the patient in semi- flower position. 

•Maintain supplemental oxygen therapy (2lit/min) 

•Assist the client in scheduling a gradual increase in daily activity and exercise

•Advise the  client to avoid conditions that increase oxygen demand such as temperature extremes, excess weight and stress. 

•Instruct the client energy conservation techniques such as pacing activities throughout day. 

 •Teach the client to use pursed-lip and diaphragmatic breathing techniques

 3.Nursing Diagnosis: Ineffective  airway clearance related to excessive production of secretions, retained secretions and ineffective coughing

Goal: The client will be maintain patent airway with breath sounds clear within hospitalization

Nursing Intervention 

•Monitor respiratory rate and auscultate breath sounds eg. wheeze, crackles, rhonchi 

 •Assist the patient to assume position of comfort eg elevate head of bed, sitting on edge of bed.

•Keep environmental  pollution to minimum eg dust, smoke and feather pillows according to individual situation 

•Encourage/ assist with abdominal or pursed lip breathing exercises  •Administer medications as indicated such as bronchodilators  •Perform chest physiotherapy.

 4.Nursing Diagnosis: Anxiety  related to disease prognosis

Nursing goal: Patient will not have any more anxiety after nursing intervention

Nursing Intervention 

•Provide  care in a calm and quiet environment. 

• Encourage the use of breathing retraining and relaxation techniques. 

•Explain the patient about disease including cause, signs and symptoms, medication, procedures, prevention and follow up care 

•Give the opportunity to talk the patient with similar problem who admitted in the same ward and almost in recovery phase.

5.Nursing Diagnosis: Risk  for infection related to ineffective pulmonary clearance

Goal: Client will have a decreased risk of infection related to ineffective pulmonary clearance after intervention

Nursing Intervention

 •Teach the client to wash his or her hands after contact with potentially infectious material. •Teach the client and family how to care for and clean respiratory equipment used at home.

• Assess vital  signs including temperature and sputum color, odor and character. 

•Teach the client and family the manifestations of pulmonary infections like change in color or volume of sputum, fever, chills, malaise, productive cough, confusion, increased dyspnea etc 

•Discuss need for adequate nutritional intake 

•Explain client about the importance of self care 

•Notify the physician if any sign of infections occurs.

PREVIOUS YEAR QUESTIONS KUHS

1) Mr. Ranganath a chronic smoker aged 65 years admitted with

breathlessness is diagnosed as a case of COPD. Define COPD and list the

causes of COPD. Discuss the findings on respiratory assessment. Explain the

nursing care of this patient using nursing process approach (1+3+4+7=15)

2. Mr. A, 55 years old chronic smoker is admitted with the diagnosis of chronic

obstructive pulmonary disease (COPD). What are the diseases included in

COPD and describe the diagnostic tests to confirm the diagnosis. Explain

the pathophysiology. Prepare a nursing care plan for this patient with

nursing assessment for three priority problems. (2+3+4+6=15)

3. Mrs. A, 55 years old man is admitted with breathlessness and diagnosed as

a case of COPD. Define COPD. Enlist the causes of COPD. Describe the

medical and nursing management of Mr A.(12)