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Obstructive And Inflammatory Lung Disease
 

Obstructive And Inflammatory Lung Disease

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    Obstructive And Inflammatory Lung Disease Obstructive And Inflammatory Lung Disease Presentation Transcript

    • N24: Class #8 Obstructive and Inflammatory Lung Disease
      • Emphysema
      • Chronic Bronchitis
      • Asthma
      Christine Hooper, Ed.D., RN Spring 2006
    • Class Objectives
      • Differentiate among the etiology, pathophysiology, clinical manifestations, collaborative care, and appropriate nursing diagnoses of the client with emphysema and chronic bronchitis.
      • Describe the etiology, pathophysiology, clinical manifestations, collaborative care, and appropriate nursing diagnoses of the client with asthma.
    • Chronic Obstructive Pulmonary Disease: COPD
      • Disease of airflow obstruction that is not totally reversible
        • Chronic Bronchitis
        • Emphysema
    • COPD: Etiology
      • Cigarette smoking #1
      • Recurrent respiratory infection
      • Alpha 1-antitrypsin deficiency
      • Aging
    • Chronic Bronchitis
      • Recurrent or chronic productive cough for a minimum of 3 months for 2 consecutive years.
      • Risk factors
        • Cigarette smoke
        • Air pollution
    • Chronic Bronchitis Pathophysiology
      • Chronic inflammation
      • Hypertrophy & hyperplasia of bronchial glands that secrete mucus
      • Increase number of goblet cells
      • Cilia are destroyed
    • Chronic Bronchitis Pathophysiology
      • Narrowing of airway
        • Starting w/ bronchi  smaller airways
      •  airflow resistance
      •  work of breathing
      • Hypoventilation & CO2 retention  hypoxemia & hypercapnea
    • Chronic Bronchitis Pathophysiology
      • Bronchospasm often occurs
      • End result
        • Hypoxemia
        • Hypercapnea
        • Polycythemia (increase RBCs)
        • Cyanosis
        • Cor pulmonale (enlargement of right side of heart)
    • Chronic Bronchitis: Clinical Manifestations
      • In early stages
        • Clients may not recognize early symptoms
        • Symptoms progress slowly
        • May not be diagnosed until severe episode with a cold or flu
        • Productive cough
          • Especially in the morning
          • Typically referred to as “cigarette cough”
        • Bronchospasm
        • Frequent respiratory infections
    • Chronic Bronchitis: Clinical Manifestations
      • Advanced stages
        • Dyspnea on exertion  Dyspnea at rest
        • Hypoxemia & hypercapnea
        • Polycythemia
        • Cyanosis
        • Bluish-red skin color
        • Pulmonary hypertension  Cor pulmonale
    • Chronic Bronchitis: Diagnostic Tests
      • PFTs
        • FVC:  Forced vital capacity
        • FEV1:  Forcible exhale in 1 second
        • FEV1/FVC = <70%
      • ABGs
        •  PaCO2
        •  PaO2
      • CBC
        •  Hct
    • Emphysema
      • Abnormal distension of air spaces
      • Actual cause is unknown
    • Emphysema: Pathophysiology
      • Structural changes
        • Hyperinflation of alveoli
        • Destruction of alveolar & alveolar-capillary walls
        • Small airways narrow
        • Lung elasticity decreases
    • Emphysema: Pathophysiology
      • Mechanisms of structural change
      • Obstruction of small bronchioles
      • Proteolytic enzymes destroy alveolar tissue
      • Elastin & collagen are destroyed
        • Support structure is destroyed
        • “ paper bag” lungs
    • Emphysema: Pathophysiology
      • The end result:
      • Alveoli lose elastic recoil, then distend, & eventually blow out.
      • Small airways collapse or narrow
      • Air trapping
      • Hyperinflation
      • Decreased surface area for ventilation
    • Emphysema: Clinical Manifestations
      • Early stages
        • Dyspnea
        • Non productive cough
        • Diaphragm flattens
        • A-P diameter increases
          • “ Barrel chest”
        • Hypoxemia may occur
          • Increased respiratory rate
          • Respiratory alkalosis
        • Prolonged expiratory phase
      • Later stages
        • Hypercapnea
        • Purse-lip breathing
        • Use of accessory muscles to breathe
        • Underweight
          • No appetite & increase breathing workload
        • Lung sounds diminished
      Emphysema: Clinical Manifestations
    • Emphysema: Clinical Manifestations
    • Emphysema: Clinical Manifestations
      • Pulmonary function
          •  residual volume,  lung capacity, DECREASED FEV 1 , vital capacity maybe normal
      • Arterial blood gases
        • Normal in moderate disease
        • May develop respiratory alkalosis
        • Later: hypercapnia and respiratory acidosis
      • Chest x-ray
        • Flattened diaphragm
        • hyperinflation
    • Goals of Treatment: Emphysema & Chronic Bronchitis
      • Improved ventilation
      • Remove secretions
      • Prevent complications
      • Slow progression of signs & symptoms
      • Promote patient comfort and participation in treatment
    • Collaborative Care: Emphysema & Chronic Bronchitis
      • Treat respiratory infection
      • Monitor spirometry and PEFR
      • Nutritional support
      • Fluid intake 3 lit/day
      • O2 as indicated
    • Collaborative Care: Medications
      • Anti-inflammatory
        • Corticosteroids
      • Bronchodilators
        • Beta-adrenergic agonist: Proventil
        • Methylxanthines: Theophylline
        • Anticholinergics: Atrovent
      • Mucolytics: Mucomyst
      • Expectorants: Guaifenisin
      • Antihistamines: non-drying
    • Collaborative Care: Emphysema & Chronic Bronchitis
      • Client teaching
        • Support to stop smoking
        • Conservation of energy
        • Breathing exercises
          • Pursed lip breathing
          • Diaphragm breathing
        • Chest physiotherapy
          • Percussion, vibration
          • Postural drainage
        • Self-manage medications
          • Inhaler & oxygen equipment
    • Asthma
      • Reversible inflammation & obstruction
      • Intermittent attacks
      • Sudden onset
      • Varies from person to person
      • Severity can vary from shortness of breath to death
    • Asthma
      • Triggers
        • Allergens
        • Exercise
        • Respiratory infections
        • Drugs and food additives
        • Nose and sinus problems
        • GERD
        • Emotional stress
    • Asthma: Pathophysiology
      • Swelling of mucus membranes (edema)
      • Spasm of smooth muscle in bronchioles
        • Increased airway resistance
      • Increased mucus gland secretion
    • Asthma: Pathophysiology
      • Early phase response: 30 – 60 minutes
        • Allergen or irritant activates mast cells
        • Inflammatory mediators are released
          • histamine, bradykinin, leukotrienes, prostaglandins, platelet-activating-factor, chemotactic factors, cytokines
        • Intense inflammation occurs
          • Bronchial smooth muscle constricts
          • Increased vasodilation and permeability
          • Epithelial damage
        • Bronchospasm
          • Increased mucus secretion
          • Edema
      • Late phase response: 5 – 6 hours
        • Characterized by inflammation
        • Eosinophils and neutrophils infiltrate
        • Mediators are released mast cells release histamine and additional mediators
        • Self-perpetuating cycle
        • Lymphocytes and monocytes invade as well
        • Future attacks may be worse because of increased airway reactivity that results from late phase response
          • Individual becomes hyperresponsive to specific allergens and non-specific irritants such as cold air and dust
          • Specific triggers can be difficult to identify and less stimulation is required to produce a reaction
      Asthma: Pathophysiology
    • Asthma: Early Clinical Manifestations
      • Expiratory & inspiratory wheezing
      • Dry or moist non-productive cough
      • Chest tightness
      • Dyspnea
      • Anxious &Agitated
      • Prolonged expiratory phase
      • Increased respiratory & heart rate
      • Decreased PEFR
    • Asthma: Early Clinical Manifestations
      • Wheezing
      • Chest tightness
      • Dyspnea
      • Cough
      • Prolonged expiratory phase [1:3 or 1:4]
    • Asthma: Severe Clinical Manifestations
      • Hypoxia
      • Confusion
      • Increased heart rate & blood pressure
      • Respiratory rate up to 40/minute & pursed lip breathing
      • Use of accessory muscles
      • Diaphoresis & pallor
      • Cyanotic nail beds
      • Flaring nostrils
    • Endotracheal Intubation
    • Classifications of Asthma
      • Mild intermittent
      • Mild persistent
      • Moderate persistent
      • Severe persistent
    • Asthma: Diagnostic Tests
      • Pulmonary Function Tests
        • FEV1 decreased
          • Increase of 12% - 15% after bronchodilator indicative of asthma
        • PEFR decreased
      • Symptomatic patient
        • eosinophils > 5% of total WBC
        • Increased serum IgE
        • Chest x-ray shows hyperinflation
      • ABGs
        • Early: respiratory alkalosis, PaO2 normal or near-normal
        • severe: respiratory acidosis, increased PaCO2,
    • Asthma: Collaborative Care
      • Mild intermittent
        • Avoid triggers
        • Premedicate before exercising
        • May not need daily medication
      • Mild persistent asthma
        • Avoid triggers
        • Premedicate before exercising
        • Low-dose inhaled corticosteroids
    • Asthma: Collaborative Care
      • Moderate persistent asthma
        • Low-medium dose inhaled corticosteroids
        • Long-acting beta2-agonists
        • Can increase doses or use theophylline or leukotriene-modifier [singulair, accolate, zyflo]
      • Severe persistent asthma
        • High-dose inhaled corticosteroids
        • Long-acting inhaled beta2-agonists
        • Corticosteroids if needed
    • Asthma: Collaborative Care
      • Acute episode
        • FEV1, PEFR, pulse oximetry compared to baseline
        • O2 therapy
        • Beta2-adrenergic agonist
          • via MDI w/spacer or nebulizer
          • Q20 minutes – 4 hours prn
        • Corticosteroids if initial response insufficient
          • Severity of attack determines po or IV
          • If poor response, consider IV aminophylline
    • Asthma Medications: Anti-inflammatory
      • Corticosteroids
        • Not useful for acute attack
        • Beclomethasone: vanceril, beclovent, qvar
      • Cromolyn & nedocromil
        • Inhibits immediate response from exercise and allergens
        • Prevents late-phase response
        • Useful for premedication for exercise, seasonal asthma
        • Intal, Tilade
      • Leukotriene modifiers
        • Interfere with synthesis or block action of leukotrienes
        • Have both bronchodilation and anti-inflammatory properties
        • Not recommended for acute asthma attacks
        • Should not be used as only therapy for persistent asthma
        • Accolate, Singulair, Zyflo
    • Asthma Medications: Bronchodilators
      •  2-adrenergic agonists
        • Rapid onset: quick relief of bronchoconstriction
        • Treatment of choice for acute attacks
        • If used too much causes tremors, anxiety, tachycardia, palpitations, nausea
        • Too-frequent use indicates poor control of asthma
        • Short-acting
          • Albuterol[proventil]; metaproterenol [alupent]; bitolterol [tornalate]; pirbuterol [maxair]
        • Long-acting
          • Useful for nocturnal asthma
          • Not useful for quick relief during an acute attack
          • Salmeterol [serevent]
    • Asthma Medications: Bronchodilators con’t
      • Methylxanthines
        • Less effective than beta-adrenergics
        • Useful to alleviate bronchoconstriction of early and late phase, nocturnal asthma
        • Does not relieve hyperresponsiveness
        • Side effects: nausea, headache, insomnia, tachycardia, arrhythmias, seizures
        • Theophylline, aminophylline
      • Anticholinergics
        • Inhibit parasympathetic effects on respiratory system
        • Increased mucus
        • Smooth muscle contraction
        • Useful for pts w/adverse reactions to beta-adrenergics or in combination w/beta-adrenergics
        • Ipratropium [atrovent]
        • Ipratropium + albuterol [Combivent]
    • Asthma: Client Teaching
      • Correct use of medications
      • Signs & symptoms of an attack
        • Dyspnea, anxiety, tight chest, wheezing, cough
      • Relaxation techniques
      • When to call for help, seek treatment
      • Environmental control
      • Cough & postural drainage techniques
    • Asthma: Nursing Diagnoses
      • Ineffective airway clearance r/t bronchospasm, ineffective cough, excessive mucus
      • Anxiety r/t difficulty breathing, fear of suffocation
      • Ineffective therapeutic regimen management r/t lack of information about asthma