Chronic Obstructive Pulmonary Disease

By GERALDINE SABATE RIDAD, RN

also known as: CHRONIC OBSTRUCTIVE LUNG DISEASE (COLD) CHRONIC OBSTRUCTIVE AIRWAY DISEASE(COAD) CHRONIC AIRFLOW LIMITATION (CAL) and CHRONIC OBSTRUCTIVE RESPIRATORY DISEASE (CORD)

a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both PROGRESSIVE and associated with an abnormal INFLAMMATORY RESPONSE OF THE LUNGS TO NOXIOUS PARTICLES OR GASES. projected to be the FOURTH LEADING CAUSE OF DEATH worldwide by 2030 due to an increase in smoking rates and demographic changes in many countries and third leading cause of death in the U.S.

CLASSIFICATION

Chronic bronchitis Emphysema Chronic bronchitis

Lung damage and inflammation in the large airways results in chronic bronchitis. Chronic bronchitis is defined in clinical terms as a cough with sputum production on most days for 3 months of a year, for 2 consecutive years. hallmark of chronic bronchitis is an increased number (hyperplasia) and increased size (hypertrophy) of the goblet cells and mucous glands of the airway. As a result, there is more mucus than usual in the airways, contributing to narrowing of the airways and causing a cough with sputum.

I-nflammation C-onstriction of smooth muscle E-xcessive mucus production

Cause: SMOKING Occupational exposures (dusts found in coal mining, gold mining, the cotton textile industry and chemicals such as cadmium, isocyanates, and fumes from welding) Air pollution long-term fume inhalation Frequent use of cooking fire without proper ventilation

Emphysema
Lung damage and inflammation of the air sacs (alveoli) results in emphysema. enlargement of the air spaces distal to the terminal bronchioles, with destruction of their walls. There are 4 types of emphysema: 1. Centriacinar / centrilobular: proximal to central parts of acini (air spaces closer to bronchioles) are affected 2. Panacinar / panlobular: enlargement of all air spaces (from bronchioles to terminal blind alveoli). This type is associated with alpha-1-antitrypsin deficiency 3. Distal acinar / paraseptal: proximal acinus normal, distal acinus affected 4. Irregular: various parts of acinus involved. Associated with fibrosis. Cause: SMOKING Hereditary deficiency of alpha-1-antitrypsin Air pollution Frequent use of cooking fire without proper ventilation

Pathophysiology

COMPLICATIONS Cor Pulmonale (pulmonary hypertension and right-sided heart failure) depression secondary polycythemia pneumothorax

Clinical Manifestation Productive cough Dypnea Wheezing Hx of smoking Barrel chest Prolonged expiration Cyanosis Chronic hypoventilation Polycythemia Cor pulmonale

Chronic Bronchitis Classic sign Late in course Intermittent Common Occasionally Always present Common Common Common Common

Emphysema Late in course w/ infection Common Minimal Common Classic sign Always present Uncommon Late in course Late in course Late in course

Diagnosis
The diagnosis of COPD should be considered in anyone who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease such as regular tobacco smoking. No single symptom or sign can adequately confirm or exclude the diagnosis of COPD, although COPD is uncommon under the age of 40 years. CONFIRMATORY TEST: pulmonary function testing (e.g. spirometry) Severity of COPD (GOLD scale) Mild (GOLD 1) Moderate (GOLD 2) Severe (GOLD 3) FEV1 % predicted 80 5079 3049 <30 or chronic respiratory failure symptoms

Very severe (GOLD 4)

A DLCO test (diffusing capacity of lung for CO) may be used to differentiate Emphysema from other types of Obstructive disorders such as Chronic Bronchitis and Asthma. A DLCO will be decreased in Emphysema whereas it will be normal or increased in Chronic Bronchitis.

Arterial Blood Gas (ABG) may show low oxygen (hypoxemia) and/or high carbon dioxide (respiratory acidosis if pH is also decreased). CBC may show a high blood count (reactive polycythemia) may aid in the diagnosis:

X-ray radiography Lung bulla as seen on CXR in a person with severe COPD (esp. on pts w/ emphysema)

useful to help exclude other lung diseases, such as pneumonia, pulmonary edema or a pneumothorax

CT-scan Electron Microscopy/ Micrography shows large empty spaces and lung tissue with relative preservation of the alveoli

Management
There is currently no cure for COPD; however, COPD is both a preventable and treatable disease. The major current directions of COPD management are to assess and monitor the disease, reduce the risk factors, manage stable COPD, prevent and treat acute exacerbations and manage comorbidity.

Emphysema
treated by supporting the breathing with anticholinergics, bronchodilators, steroid medication (inhaled or oral), effective body positioning (High Fowlers), and supplemental oxygen as required. Lung volume reduction surgery (LVRS) can improve the quality of life for certain carefully selected patients. The only known "cure" for emphysema is LUNG TRANSPLANT, but few patients are strong enough physically to survive the surgery. The combination of a patient's age, oxygen deprivation and the side-effects of the medications used to treat emphysema cause damage to the kidneys, heart and other organs. Surgical transplantation also requires the patient to take an anti-rejection drug regimen which suppresses the immune system, and can lead to microbial infection of the patient. With the discovery of MULTIPOTENT LUNG STEM CELLS in 2011, a new treatment option may soon become available. Scientists injected human lung stem cells into mice with damaged lungs. The stem cells formed human bronchioles, alveoli, and pulmonary vessels integrated structurally and functionally with the damaged mouse organ. The May 2011 report in the New England Journal of Medicine concluded that human lung stem cells "have the undemonstrated potential to promote tissue restoration in patients with lung disease".

Chronic bronchitis
Antibiotics Only about 5-10% of bronchitis cases are caused by a bacterial infection. Most cases of bronchitis are caused by a viral infection and are "self-limited" and resolve themselves in a few weeks. For acute exacerbations of chronic bronchitis, if antibiotics are used, AMOXICILLIN OR DOXYCYCLINE is recommended.

 Bronchodilators IPRATROPIUM is an example of a bronchodilator that may be useful for people suffering from chronic obstructive pulmonary disease, such as chronic bronchitis. ALBUTEROL is also a common drug for this disease. For ACUTE EXACERBATIONS: 1. Corticosteroids 2. Cough suppressants 3. Theophylline 4. Oxygen therapy

Risk factor reduction

Smoking cessation Occupational health education of workers and management about the risks, promoting smoking cessation, surveillance of workers for early signs of COPD, the use of personal dust monitors, the use of respirators and dust control. Dust control can be achieved by improving ventilation, using water sprays and by using mining techniques that minimize dust generation. If a worker develops COPD, further lung damage can be reduced by avoiding ongoing dust exposure, for example by changing the work role. pollution reduction efforts Pulmonary rehabilitation influenza vaccinations and pneumococcal vaccinations if appropriate
COMMON NURSING DIAGNOSIS Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Anxiety Fatigue Fear Interrupted family processes Risk for infection

REFERENCES: Anatomy and Physiology 5th Ed. By Gary A. Thibodeau and Kevin Patton Essentials of Human Anatomy and Physiology 7th ed. by Elaine N. Marieb Brunner & Suddarths Medical-Surgical Nursing 11th by Smeltzer, et. al. Volume 1 MEDICAL SURGICAL NURSING, Clinical Management for Positive Outcomes, 7th Edition, by Joyce M. Black and Jane Hokanson Hawks, Volume 1 Understanding Pathophysiology 3RD ed. by Sue Huether and Kathryn McCance http://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_disease http://en.wikipedia.org/wiki/Emphysema http://en.wikipedia.org/wiki/Chronic_bronchitis