Kathy Wollschleger-Careplan

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Chronic Obstructive Pulmonary Disease, often referred to as COPD, is a chronic, progressive disease of the lower respiratory tract, characterized by diminished inspiratory and expiratory function of the lungs. COPD includes other respiratory conditions, specifically chronic bronchitis and emphysema. In chronic bronchitis, there is a chronic inflammation of the lower respiratory tract characterized by a cough with sputum production on most days lasting three months of a year, for two or more consecutive years. In the airways of the lungs, there is an increased number and size of goblet cells and mucous glands of the airway resulting in the production of excess mucus in the airways, contributing to the narrowing of the airways and causing an ongoing cough with sputum production. Emphysema is a complex lung disease characterized an enlargement of the air spaces distal to the terminal bronchioles with destruction of their walls and also resulting in destruction of the alveoli, the air sacs in the lungs where exchange of oxygen and carbon monoxide takes place, enlargement of the distal airspaces between the alveoli, and a breakdown of the alveolar walls. These airways are more likely to collapse causing further limitation of air flow. In normal healthy lungs, air and oxygen pass through the upper respiratory tract through the bronchi, traveling then through the bronchioles and into the alveoli where the gas exchange of oxygen and carbon dioxide take place. Alveoli are tiny hollow sac-like structures where oxygen is absorbed into the blood. In COPD, there is a loss of elasticity in both the bronchioles and the alveoli, and destruction of the walls of the alveoli, causing swelling and inflammation. There is also an abnormally large amount of mucous secretion, which can block the airways resulting in ineffective breathing. The air flow upon expiration becomes difficult or sometimes blocked making it difficult to breathe effectively. Because the airways become narrowed, the exchange of oxygen and carbon dioxide in the alveoli is compromised. The airflow limitation is progressive and not fully reversible. Although COPD affects the lungs, it also produces significant systemic consequences. One is cor pulmonale, which is an abnormal cardiac condition characterized by enlargement of the right ventricle in the heart as a result of hypertension of the pulmonary circulation. This can result in edema in the lower extremities, sacral and peritoneal areas, distended neck veins, and enlargement of the liver with ascites (accumulation of fluid and albumin in the peritoneal cavity). Other complications resulting from COPD are respiratory failure, pneumothorax(collection of air or gas in the pleural space, causing the lung to collapse), and bronchiectasis (abnormal permanent dilation of one or more large bronchi). Risk factors for the development of COPD include the following: A) Smoking B) Environmental Factor including air pollution, occupational exposure to harmful lung irritants

C) Genetic predisposition, aging

COPD develops most often as a result of smoking and accounts for as many as nine out of ten deaths related to COPD. These can be individuals who currently smoke or have smoked in the past creating irreversible damage to the lungs. Even those individuals who do not smoke but have long-term contact with second-hand smoke can develop COPD. COPD can also occur in individuals that have experienced a long-term exposure to harmful pollutants or whose workplace included harmful lung irritants such as chemicals, dusts or fumes. Even if an individual has never smoked nor been exposed to harmful pollutants, they could still develop COPD due to a Alpha-1 Antritrypsin(AAT) Deficiency, which is a protein in the blood. Without this specific protein, white blood cells begin to harm the lungs and causes lung deterioration to occur. There are stages that outline the progression of COPD: STAGE ONE MILD COPD airflow is mildly limited, and the individual may not even know that the lung function may be abnormal STAGE TWO MODERATE COPD limited airflow is causing more pronounced symptoms such as shortness of breath on exertion and individuals may seek medical care STAGE THREE SEVERE COPD there is an increased worsening of symptoms, repeated exacerbations and further decline in lung function STAGE FOUR VERY SEVERE COPD - airflow is severe, symptoms are severe and exacerbations may be life threatening An important role of the nurse is to obtain the symptoms and signs of COPD for the physician to make an accurate assessment on the patient. Because COPD is characterized as a progressive, chronic disease, with both chronic bronchitis and emphysema making up the manifestations, signs and symptoms will vary depending on the stage of the disease. It is important upon collecting subjective data (or symptoms) from the patient is to obtain a history of the onset of the symptoms and the intensity of each symptom. Symptoms (or subjective data) to be collected from the patient may include the following: 1) Shortness of breath or dyspnea 2) Presence of a productive cough lasting at least 3 months a year over a period of two successive years with production of thick sputum, greater amounts being produced in the event of an infection 3) Feeling of breathlessness, even upon doing normal activities of daily living 4) Fatigue or weakness 5) Headaches 6) Anxiety 7) Difficulty sleeping or need to sleep in sitting position in order to effectively breathe

8) Constant feeling of breathlessness 9) Decreased cognitive function It is important for the nurse to then gather objective information (or signs) which may include the following, depending on the stage of the disease: 1) Full patient history (including history of smoking, exposure to any air irritants, family history pertaining history of respiratory disorders, if patient has had chronic cough, will need to obtain length of time, constant or intermittent, and sputum production, history of any abnormal sleep patterns) 2) Loss of weight (could be due to patients need to use all of his/her energy (metabolic state increased) just to breathe 3) Tachycardia (due to heart involvement with respiratory distress) 4) Tachypnea (difficult and labored breathing) 5) Presence of adventitious lung sounds upon auscultation (wheezes, rhonchi, rales) 6) Sputum expectoration (noting consistency and color) 7) Noting patient breathing through pursed lips from difficulty in expiration of air from lungs 8) Orthopnea (Noting patients position in breathing is patient leaning forward to facilitate breathing ) 9) Skin color change (pallor of skin or later signs of peripheral cyanosis may appear due to lack of oxygen to body systems) 10) Appearance of barrel chest due to air trapping with diaphragmatic flattening 11) Clubbing of fingers (later stages of COPD) 12) Hypoxemia 13) Muscle atrophy due to patients inability to perform any type of physical activity Diagnostic tests that will be used in the diagnosis of COPD are as follows: 1) Chest x-ray: May reveal trapping of air within lungs; hyperinflation; increased anterior-posterior diameter or flattened diaphragm, pulmonary artery enlargement, and/or bullae (areas of destroyed lung tissue that create large dilated air sacs) 2) CT-Scan: will detect presence of emphysema 3) Pulmonary Function Tests: measures how well lungs are moving air in and out and how well lungs are moving oxygen into the blood 4) Spirometry: series of tests that measure how much air a patient can breathe in and out and how fast a patient is breathing that volume of air. Tests under this include: a) Forced vital capacity (FVC): measures amount of air you can breathe out in one complete breath b) Forced expiratory volume in first second (FEV1): measures how much air you blew out was breathed in first second c) Peak expiratory flow or peak flow (PEF): measures how fast air is breathed out from the lungs

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d) Mid Breath Forced Expiratory Flow (FCF25-70): measures how fast you breathe out air from 25% of your breath to 75% of your breath Lung Volume Tests: a) Total Lung Capacity Test (TLC ): measures the maximum amount of air your lungs can hold after breathing in on inspiration b) Residual Volume (RV): measures the amount of air remaining in the lungs after you physically breathe out all of the air you can c) Diffusing Capacity (DLCO): shows how well oxygen moves from the lungs to the blood Arterial Blood Gas (ABG): blood drawn from an artery to determine how well lungs are getting oxygen into blood and getting carbon dioxide out of blood Pulse Oximetry: will show percentage of oxygen in blood Sputum Culture: to determine if there is a bacterial/viral infection present CBC: may detect higher volume of red blood cells indicative of polycythemia due to chronic hypoxemia Alpha-1 Antitrypsin Deficiency Testing: to test if individual has this protein deficiency, one of the most common genetic risk factors for COPD

Treatment for persons suffering from COPD is designed to relieve symptoms and prevent further complications. Since most COPD receive treatments on an out-patient basis, treatment should commence with patient teaching to help the patient comply with the recommended therapy and understand the nature of this chronic, progressive and irreversible disease process. The following are various treatments/patient teaching involved with the management of COPD: 1) Cessation of smoking. It is important that the patient understand the damaging effect Smoking has on the lungs. A nurses role could be to assist patient in obtaining smoking cessation products and/or programs and monitor follow-up of the patients compliance to not smoking 2) Home oxygen therapy. This is intended for the patient to continue oxygen therapy at home after discharge from the hospital for patients with hypoxemia. Teach the patient how to use the equipment correctly. Patients with COPD should only administer up to two liters of oxygen therapy through a nasal canula for adequate oxygenation(air flow any higher than two liters is dangerous since it can diminish the brains respiratory center and cause respiratory failure 3) Inhaled bronchodilators which can reduce dyspnea and bronchospasms. They are delivered by metered dose inhalers (MDI) or handheld or mask nebulizer devices(i.e.-ipratropium bromide, albuterol-anti-cholinergic bronchodilators) or long acting beta2-receptor agonists: (i.e.-salmeterol/fluticasone or Symbicort) 4) Methylxanthines (i.e.theophylline), which are classified as a bronchodilator/antiinflammatory agent, and are given orally or as a sustained-release formulation for chronic maintenance therapy 5) Corticosteroids (ie.-prednisone). Given to treat inflamed airways.

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Mucolytics may be given to break up secretions and allow mucus to be cleared more effectively from the airways Antibiotic therapy in event of respiratory infection (i.e.-azithromycin, ampicillin, erythromycin) Pulmonary rehabilitation to improve function, strength, disease self-management techniques, independence and better quality of life, usually performed by respiratory therapists Mucus Clearance device . A small hand-held object shaped like a pipe and patient blows into it creating a vibration on the chest to loosen mucus for expectoration. This should be used prior to administration of nebulizer/inhalants for the medication to be able to penetrate the lung tissue effectively) Chest physiotherapy, including percussion, vibration and postural drainage to loosen secretions to be expectorated Treatment for alpha1-antitrypsin deficiency, if this is the cause for COPD Vaccinations: Influenza virus vaccine every year and pneumococcal revaccination every five years

In the event that none of the above treatments prove to be effective to treat the patient with COPD, two surgical procedures can be performed. One surgical procedure is a lung volume reduction surgery, whereby the upper portion of the diseased lung is removed. This is usually done with individuals suffering from emphysema, one of the conditions that make up COPD. It is believed that by removing the portion of the diseased lung, it can create more space in the chest for the remaining lung tissue to expand. It has proven effective for individuals suffering from emphysema that affects the upper lobes. The other surgical procedure is a lung transplant, involving one or both lungs. Since donor lungs are scarce, an individual must undergo extensive screening to see if he/she is a candidate for this major surgery. The patient must meet disease-specific criteria for severe end-stage lung disease, yet able to live and wait for one or both donor lungs to become available, undergo the extensive surgery and postoperative period. After surgery, the individual will be required to take medications for the rest of their lives to suppress the immune system to prevent the risk of rejection of the donor lung(s). The most common problem related to rejection is a condition called bronchiolitis obliterans, in which the bronchioles become blocked. Nursing implications play a major role in treating a patient with COPD and include patient teaching. They are directed to decreasing the patients anxiety and promoting air exchange. It is important to teach the patient about their disease and explain that the disease can cause irreversible problems. If a patient has been hospitalized for an exacerbation of COPD, nursing interventions in the hospital would include: 1) Auscultate lungs every two hours for adventitious lung sounds and report changes to physician

2) Take vital signs every two to four hours, including pulse, temperature, respirations and blood pressure and document accordingly; any adverse findings should be reported to physician 3) Elevation of the head of the bed to assist in breathing 4) Administration of low-flow oxygen as ordered (normally 1-2 L by nasal cannula) 5) Chest physiotherapy, including percussion, vibration and postural drainage to help loosen the secretions to be expectorated to be performed every four hours 6) Increasing fluid intake to 2-3 liters a day to help liquefy secretions 7) Encourage coughing and deep breathing to be done every hour or as necessary 8) Suction patient if unable to effectively bring up secretions 9) Change patients position every two hours 10) Assist with nebulizer respiratory treatments as ordered by physician 11) Administration of respiratory medications prescribed by physician 12) Organize periods of ambulation with portable oxygen tank and walker to build up patients tolerance to activity and allow rest during activity 13) Assist patient with active range of motion exercises in bed to build up stamina 14) Monitor patients respiratory response to activity 15) High-protein, high calorie diet should be provided into five to six small meals a day to maintain adequate nutritional status and monitor percentage of meals eaten daily 16) Monitor daily input and output and document accordingly 17) Monitor any laboratory tests ordered and report any abnormal findings to physician

Upon discharge from the hospital, further patient teaching should include providing patients with information on possible signs and symptoms to be aware of in times of exacerbation of the disease and to contact their physician upon the onset of these symptoms immediately so that treatment can be commenced. A nurse can assure the patient that there will be medications prescribed upon discharge for them to take at home to manage the COPD and the importance of staying on any medications ordered with no abrupt cessation. The nurse should provide the patient with possible side effects of the drugs prescribed and to alert the patient to contact their physician immediately if any of the side effects occur. A key factor involved with patient teaching is to provide information to the patient on how they can improve their own lifestyle to lead a more productive life. These would include the following: 1) Cessation of smoking. By teaching the patient the implications of smoking with COPD, it is hopeful that a patient may willingly wish to quit smoking to prolong their life. Assist the patient in formulating a workable cessation program including medications and counseling and take the actual steps in putting the plan together for the patient by organizing the medications available, counseling appointments and follow-up care 2) If a patient is sent home on oxygen therapy, it is important to teach the patient how to use the portable oxygen tank and to make sure that the level of oxygen to be administered should be no higher than 2 liters

3) Patient should continue their deep breathing and coughing exercises as taught while in the hospital especially during episodes of dyspnea or stress 4) Lifestyle changes would include pacing themselves for daily activities, allowing rest when fatigued. They should do their daily activities when their energy level is at the highest, such as after administration of their daily medications. Recommend rest periods an hour before and an hour after meals. 5) Other daily activities that could be modified include: a) using a shower chair in the shower instead of standing to conserve energy; b) do not use aerosol sprays such as hairspray, deodorant, strong perfumes , aerosol paints, or products such as bleaches or ammonias that could cause irritation to the lungs; use a fan in the kitchen to filter out any cooking smoke that could be irritating and keep the house well ventilated 6) Recommend a pulmonary rehabilitation program geared to reconditioning of the upper body and strengthening of the respiratory muscles and breathing instruction to teach the patient to effectively slow the rate of breathing and resting the upper respiratory muscles by using abdominal breathing 7) Stress the importance of eating nutritional foods high in protein and calories but to eat five to six smaller meals a day and to rest at least 30 minutes prior to eating and resting at least an hour after eating to conserve energy and avoid dyspnea; it should also be suggested that a patient drink fluids between meals instead of with meals to reduce the possibility of gastric distention and pressure on the diaphragm 8) Teach patient to avoid extremely hot/cold weather to avoid possible bronchospasm or dyspnea 9) Instruct patient to use a humidifier in the home to maintain 30% to 50% humidity and suggest the use of a HEPA air filter to remove any dust, pollen or other irritants from the air 10) Teach the patient relaxation techniques to assist them to control anxiety 11) Allow the patient to express any feelings they may have dealing with the disease and be a good listener and show that you care 12) Instruct the patient to avoid anyone with any type of infection that could compromise their own respiratory health 13) Actively involve family members of the patient in home care after discharge from the hospital 14) Refer to social services or the county health department for possible follow-up in home maintenance and nursing follow-up upon patient discharge if needed The prognosis for a patient with COPD depends on the severity of the disease upon detection. If the patient is willing to stop smoking and obtains effective treatment, it will help to prolong the life of the patient. However, this disease is irreversible and there is no cure for the damage that has taken place. It is therefore very important to assist the patient to live the most productive life that they can with the proper limitations instituted.