Advanced Practice Powerpoint

Obstructive Lung Disease
KimberlyAugustine BSRN

Objectives
Define Obstructive Lung Disease
Epidemiology
Pathophysiology
Identify Clinical manifestations
Identify Risk factors
Discuss Evaluation & Treatment

Definition
Several different definitions have existed for COPD.
“ 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 lung to noxious particles or gases.”-GOLD
A group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema, chronic bronchitis, and in some cases asthma.-CDC
“ Airway obstruction:most common obstructive diseases are asthma, chronic bronchitis, emphysema-McCane & Huether

Obstructive Pulmonary Disease
Obstructive Diseases
Include:
Chronic bronchitis
Emphysema
Asthma

Epidemiology
4th leading cause of death in the U. S.
12.1 million U.S. adults were estimated to have COPD
Women have exceeded men in the number of deaths attributable to COPD
2010, $49.9 billion COPD health care costs
Worldwide leading cause of death & disability
2020, predicted 3 rd leading cause of death

Pathophysiology: Video
http://www.youtube.com/watch?v=lYW_2Rfuii8&feature=related

Obstructive Lung Disease: Emphysema
“ A condition which the lungs lose elasticity and alveoli enlarge that disrupts function”
Destruction of lung parenchyma
Loss of elastic recoil
Alveolar gas is trapped in expiration
Gas exchange is compromised

Pathophysiology: Emphysema
Begins with the destruction of air sacs (alveoli) in the lungs where oxygen from the air is exchanged for carbon dioxide in the blood.
The walls of the air sacs are thin and fragile. Damage to the air sacs is irreversible and results in permanent "holes" in the tissues of the lower lungs.
As air sacs are destroyed, the lungs are able to transfer less and less oxygen to the bloodstream, causing shortness of breath.
The lungs also lose their elasticity, which is important to keep airways open. The patient experiences great difficulty exhaling.

COPD: Emphysema

COPD: Emphysema Signs & Symptoms
Dyspnea
Little sputum production or cough
Tachypnea with prolonged expiration
Use of accessory muscles for ventilation
Increased anteroposterior diameter of thorax (Barrel Chest)
Pierced Lips to prevent expiratory airway collapse
Cardiac enlargement
Hyperresonant (loud, low) sound with chest percussion d/t hyperinflation

Obstructive Lung Disease: Chronic Bronchitis
“ The presence of a mucus-producing cough three months of a year for two consecutive years without other underlying disease to explain the cough.”
Inflammation and eventual scarring of the lining of the bronchial tubes
Inflamed, infected bronchi allow for less air to flow to and from the lungs and a heavy mucus or phlegm is coughed up

Pathophysiology: Chronic Bronchitis
Increased mucous production
Increase in size, number goblet cells
Impaired Ciliary function
Bronchospasm, permanent narrowing of airways
Decreased ventilation
Tidal Volume Decreased
Hypoventilation
Hypercapnia

COPD: Chronic Bronchitis

COPD: Chronic Bronchitis Signs & Symptoms
Wheezing and shortness of breath
Productive cough “smoker's cough”
Decreased tolerance, hypoxic with exercise
Frequent pulmonary infections
Decreased FEV1, FEC
FRC & RV increased
Increased Paco2, Hypoxemia, Polycythemia
Cyanosis “Blue Bloater”

Risk Factors: COPD (Emphysema & Chronic Bronchitis)
Smoking predominant Cause
Alpha-1antitrypsin deficiency
Occupational exposure, pollution
Diet deficient in vitamin C
Low Birth weight
Childhood respiratory infections
Pre-existing bronchial hyper-responsiveness
Low social class

Global Initiative: COPD

Potential Complications: COPD
Hypoxemia (paO2 of 55mmHg or less with an oxygen saturation of 85% or less)
Cor Pulmonale (Right Sided Heart Failure)
Respiratory Acidosis & Hypercapnia (increased paCO2):

Oxyhemoglobin Dissociation Curve
The oxyhemoglobin dissociation curve is an important tool for understanding how our blood carries and releases oxygen. Specifically, the oxyhemoglobin dissociation curve relates oxygen saturation (SO 2 ) and partial pressure of oxygen in the blood (PO 2 ), and is determined by what is called "hemoglobin's affinity for oxygen," that is, how readily hemoglobin acquires and releases oxygen molecules from its surrounding tissue.

Potential Complications: COPD
Hypoxemia (paO2 of 55mmHg or less with an oxygen saturation of 85% or less)
Mood changes
Forgetfulness
Inability to concentrate
Cyanosis a late sign of hypoxia

Potential Complications of COPD
Respiratory Acidosis & Hypercapnia (inc. pCO2):
Decrease in oxygen/carbon dioxide exchange
Rising carbon dioxide levels result in respiratory acidosis (CO2 makes ACID)
SOB (increased Respiratory rate)
Headache
Confusion
Lethargy
Nausea and Vomiting

Potential Complications COPD
Cor Pulmonale (Right Sided Heart Failure)
Progressive shortness of breath with activity
Chest pain under sternum
Weakness
Neck vein distention, edema
Enlarged liver
Right ventricular hypertrophy

Obstructive Lung Disease: Asthma
“ Chronic inflammatory disorder of the airways involving hyper-responsiveness and airway obstruction”
Periods of attacks of wheezing shortness of breath
Tight feeling in the chest
Cough that produces mucous
Due to an allergic reaction
Triggered by certain drugs, irritants, viral infection, exercise emotional stress

Pathophysiology: Asthma
Familial
Allergen Exposure initiates immune response
IL-4 activates IgE production, mast cell degranulation
Releases histamine, prostaglandins, leukotrienes
Bronchospasm, congestions, mucous production
Bronchial Hyper-responsiveness

Asthma: Signs & Symptoms
Asymptomatic between attacks
Chest constriction
Expiratory Wheezing
Dyspnea
Non productive cough
Tachycardia, tachypnea
Pulsus Paradoxus

Asthma: Signs & Symptoms (Cont.)
Hypoxemia with low pCO2
Respiratory fatigue/failure: pco2 may rise
Eosinophilia (allergy)
Decreased FEV1
Decreased peak expiratory flow rate

Risk Factors: Asthma

Asthma: EvaluationTreatment
Treat precipitating event
Oxygen therapy
Hydration
Antibotics (with infection)
Meds: bronchodilators, steroids, mast cell stabilizers, methylxanthines

Nursing Diagnosis: COPD
Ineffective airway clearance r/t
Airway spasm
Retained secretions
Excessive mucous
Fatigue
Impaired gas exchange r/t
Descreased lung expansion
Decreased LOC
Presence of pulmonary secretions

Nursing Diagnosis: COPD
Ineffective breathing patterns r/t
Hyperventilation
Hypoventilation
Anxiety
fatigue

Planning (Goals)
Breath sounds clear A&P
Respirations between 12-20/min
SaO2 90% or greater
Ambulate ___ feet QID

Implementation: Promoting Lung expansion
Positioning
Breathing exercises
Chest Physiotherapy
Oxygen Therapy

Positioning: change at least Q2 hrs

Breathing exercises: to expel secretions from lungs
CDB Q2 hrs
Pursed lip breathing
Helps COPD patients to evacuate more air by breathing out against pressure
Abdominal Breathing (diaphragmatic)
Promotes alveoli expansion and emptying

Implementation: Mobilizing Pulmonary Secretions
Hydration
Keeps pulmonary secretions moist, easy to expectorate
Fluid intake 1500-2000 cc/day
Humidification
Air or oxygen with increased humidity will help to keep airways moist to loosen and mobilize pulmonary secretions
Nebulization
Adding fine drops of moisture to the respiratory tract

Chest physiotherapy
Chest percussion (cupping)
Vibration: fine shaking pressure applied to chest wall only during exhalation (helps get rid of trapped air) vest

Chest physiotherapy
Postural Drainage: positioning
(not good for emphysema/bronchitis don’t tolerate asthma not needed. Just for CF-bronchitis w/o emphesema

Case Study

Journal Article: COPD the role of the nurse by Barnett
Nurses have a key role in the prevention and treatment of COPD in advising and supporting patients living with this condition.

Nurses Role
Prevention & Treatment
Recognize clinical symptoms
Recognize Associated Risk Factors
Medications Available
Effectiveness(Questions)
Patient Education:
Smoking
Nutrition
Activity
Vaccination

Discussion
Patient Factors for COPD/Single Most Factor
Clinical Manifestations of Bronchitis/Emphysema
COPD Staging
Arterial Blood Gas indicative of which Serious Condition
Pulmonary HTN/Cor Pulmonale Clinical Manifestations

Restrictive vs Obstructive Disease
http:// www.youtube.com/watch?v = wbcjFpyxkpc&feature =related http://www.youtube.com/watch?v=wbcjFpyxkpc&feature=related

References
Barnett, Margaret. (2006, February). COPD: the role of the nurse. Journal of Community Nursing, 20(2), 18-20,22. Retrieved October 26, 2010, from Research Library. (Document ID: 989426231).
Bauldoff, G. (2009). When breathing is a burden: how to help patients with COPD. American Nurse Today, 4(9), 17-22. Retrieved from CINAHL database.
National Heart Lung and Blood Institute http://www.nhlbi.nih.gov/health/public/lung/copd/ .
American Lung Association http://www.lungusa.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html

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