Learning Objectives1. Describe anatomic changes in the lungs resulting from the normal aging process.2. Describe age related changes in ventilation.3. List nursing diagnoses for older adults with respiratory diseases.4. Identify nursing interventions and outcomes for older adults with various respiratory alterations.5. Discuss smoking cessation methods and interventions.6. Identify risk factors for the development of tuberculosis in older adults.7. List the benefits of pulmonary rehabilitation for older adults with chronic obstructive pulmonary disease.
Respiratory System Components Lungs Airways leading to the lungs Blood vessels serving the lungs Chest wall
Normal Aging Changes Differentiatingnormal aging changes from disease-related changes is difficult. Lung structure and function with normal aging include Stiffeningof elastin + collagen connective tissue supporting the lungs Altered alveolar shape increased alveolar diameter Decreased alveolar surface area available for gas exchange Increased chest wall stiffness
Thoracic cage The ribs become less mobile and the compliance of the chest wall decreases Osteoporosis and calcification of the costal cartilage Kyphosis or Scoliosis degeneration of the intervertebral => shorter thorax with an increased AP diameter
Respiratory muscles Respiratory muscles weaken => Inspiratory and expiratory forces are decreased The diaphragm does not lose mass with aging but it may flatten and become less efficient specially in patients with COPD Older adults use the less efficient accessory muscles of respiration such as the abdominals, sternocleidomastoid and trapezius muscle
Breathing patterns More dependent on intraabdominal pressure changes and positioning Normal rate of 16 to 25 breaths/min Decrease in tidal volume (Vt) Alveoli at the base of the lungs are underventilated => hypoxemia and hypercarbia
Lung Parenchyma Progressiveloss of elastic recoil of the lung parenchyma and conducting airways => respiratory system compliance decreases Lungbecomes less elastic as collagenic substances surrounding the alveoli and alveolar ducts stiffen and form cross linkages
Lung Capacity Total lung capacity (TLC) changes little with age Vital capacity (VC) is decreased Rate of reduction of VC is greater in older men than in older women Decreased compliance of the thorax accounts for the increase in residual volume (RV) and expiratory reserve volume (ERV).
Lung Capacity Inspiratorycapacity of older adults is affected by the decreased ability to take a deep breath Functionaldead space ventilation in increased from one third to as much as one half of each breath
Airway Affected by four factors: (1) Size of the airway (2) Resistance in the airway (3) Muscle strength (4) Elastic recoil. When measured in the older client, all of these indices are decreased Early airway closure is seen in older clients
Alveoli Alveoli decrease in number Progressive loss of the intraalveolar septum Alveolienlarge because of dilation of the proximal bronchioles
Immune system Decrease in the number and effectiveness of cilia => increased difficulty in clearing secretions and increased risk for the development of respiratory tract infections Alveolar macrophage activity is defective Decreased IgA
Gas Exchange PaO2 falls at a rate of 4 mmHg per decade of life. A normal PaO2 for a 70 year old is between 75 and 80 mmHg. “70 at 70” Fall in PaO2 is most likely caused by an increased closing volume during tidal breathing.
Cardiovascular Changes Affecting the Pulmonary System Increased stiffness of heart + blood vessels vessels less compliant to increased blood flow demands Impaired diastolic filling diastolic dysfunction Increased left ventricular afterload systolic dysfunction Decreased cardiac output with rest and exercise oxygen-carrying capacity(hemoglobin x 1.34) of the blood is reduced with age The arterial pH of the older person remains within normal adult range of 7.35 to 7.45 less increase in heart rate and a lower response to increasing carbon dioxide
Normal Aging of Immune Function Can Affect Pulmonary Function Decrease in the nature + quantity of antibodies produced Cilia less effective in removing debris more foreign bodies in lungs Decreased antibody production after immunization Use of medications suppress immune function
Neurological Changes ofAging and the RespiratorySystem Neuronloss in the brain and central nervous system Increased reaction time Decreased response to multiple complex stimuli Impaired ability to adapt and interact with the environment
Changes That AffectPulmonary Function Loss of muscle tone Exacerbated by deconditioning + sedentary lifestyle Increased thoracic rigidity Osteoporotic changes to the spine (kyphosis)
Changes That AffectPulmonary Function Medication use Fatigue Depressed cough reflex Insomnia Dehydration Bronchospasm
Changes Affect PulmonaryFunction Diagnosis of neurological disease or impairment Dementia Parkinson’s disease Stroke or CVA Increasedanteroposterior diameter of thorax barrel chest appearance
Exercise and Immobility Exercisehas a positive effect on the respiratory and cardiovascular systems
Smoking Smoking has long been known to damage the lungs. Recently prolonged exposure to secondhand smoke has been shown to damage the lungs of nonsmokers. Heavy smokers may demonstrate a ninefold increase in the reduction of Forced Expiratory Volume over normal expected reductions. Cilia, which are paralyzed by nicotine, are unable to clean the lungs
Smoking Cigarette smoking causes bronchoconstriction, increased airway resistance and increased closing volumes Smoking interferes with gas exchange because the carbon monoxide byproduct competes with oxygen for the hemoglobin molecule
Smoking Cessation Smoking cessation is imperative. The five components of smoking cessation consist of THE 5 AS: ASK, ADVISE, ASSESS, ASSIST AND ARRANGE.NEW TREATMENTS : bupropion hydrochloride, nicotine gum, nicotine patches and nicotine inhalation systems. Bupropion hydrochloride given for 3 days at 150 mg per day and then increased to 150 mg twice a day with doses 8 hours apart and the first dose in the morning. Older clients are encouraged to smoke during the first week of treatment and to set a quit smoking date before the end of the first 14 days treatment
Obesity Obesityresults in a decrease in chest wall compliance. Inolder clients with already decreased chest wall mobility and stiffening of the chest, added weight greatly reduces pulmonary functions and increases breathlessness. Ventilationat the bases of the lungs may be diminished because of the clients inability to take a deep breath
Sleep Increased sleep time of older adults increases the risk of aspiration and oxygen desaturation during sleep
Anesthesia and Surgery An older client undergoing surgery has an increased risk of aspiration as a result of loss of laryngeal reflexes. If surgery is an emergency, risk in increased because of the older clients delayed gastric emptying and the potential for a full stomach. Incisions, pain and decreased postoperative deep breathing increase the older clients chance of developing postoperative atelectasis.
Anesthesia and Surgery Subsequent immobility decreases ventilation and effective airway clearance. Hypovolemia contributes to thickened secretions. Because older clients have a less effective cough, a painful incision further diminishes the likelihood of effective airway clearance. Promotion of deep breathing, adequate hydration, frequents position changes and early mobilization will decrease the risk of developing atelectasis
Common Respiratory Symptoms elevated respiratory rate of 16 to 25 breaths/min Abnormal breathing patterns in older clients can be indicative of other metabolic and respiratory illnesses change in the mental status – 1st sign responses to hypoxemia and hypercapnia are blunted
Common Respiratory Symptoms Dyspnea is a perception of breathlessness Older clients most often describe their breathlessness as a sensation of an inability to get enough air, or a choking or smothering feeling. associated with an acute respiratory or cardiac illness most common complaint in older clients with pulmonary disease. older clients usually do not complain of dyspnea until it begins to interfere with their activities of daily living (ADLs)
Common Respiratory Symptoms cough mechanism Causes of coughing in older clients include postnasal drip, chronic bronchitis, acute respiratory tract infections, aspiration, gastroesophageal reflux, congestive heart failure (CHF), interstitial lung disease, cancer and angiotensin- converting enzyme inhibitor medications for hypertension and CHF. recommend cough suppressants with caution Suppression of the cough and depression of any respiratory function could lead to retention of pulmonary secretions, plugged airways and atelectasis.
COPD characterized by airway obstruction and decreased expiratory flow rate The 2 reversible components in COPD are airway diameter and expiratory flow rate Emphysema, chronis bronchitis, and bronchiectasis are often referred to as COPD progressive and ultimately fatal disease more than two times high in men as in women between the ages of 65 and 74 and three times as high between ages of 75 nad 84
COPD Rick factors for COPD include: age, male gender, reduced lung function, air pollution, exposure to secondhand smoke, familial allergies, poor nutrition, and alcohol intake. COPD is often a comorbid factor in deaths from pneumonia and influenza, and it accounts for increased physician visits.
COPDSymptoms: Depending on whether emphysema or chronic bronchitis is the predominant factor. Symptoms include dyspnea (especially on exertion), cough, sputum production, weight loss, and fatigue. Diagnosis is based on client history and alterations in the PFTs.
Diagnostic Tests and Procedures history exposure to tobacco smoke; occupational dusts and chemical; smoke from home cooking and heating fuels; and progressive dyspnea, chronic cough, and chornic sputum production, usually in the morning. PFTs or simple spirometry is used for the initial diagnosis of airflow obstruction. A resting ABG measurement a standard baseline posteroanterior chest x- ray study are also obtained. The blood hemoglobin level is staged based in the percent if the predicted value of FEV₁.
Nursing ManagementASSESSMENT Assessing their ADLs, quantifying breathlessness on a scale of 1 to 10, and identifying environmental and social factors Precipitating factors Physical assessment includes assessment of the shape and symmtery of the chest; respiratory rate and pattern; body position; use of accessory muscles of respiration; color, temperature, and appearance of extremities; and sputum color, amount, consistency, and odor.
Nursing Management Assess cyanosis in darkly pigmented older adults, the nurse shouls examine the client with favorable lighting conditions (e.g., use overbed light or natural sunlight). The lips, nail beds, circumoral region, cheek bones and earlobes. Changes in level of consciousness, increased respiratory rate, use of accessory muscles of respiration, nasal flaring, and positional changes and other manifestations of respiratory distress. Fremitus, chest wall movement, and diaphargmatic excursion
Nursing ManagementDIAGNOSIS Nursing diagnoses common for an older client with COPD include: Ineffective airway clearance related to retained secretions. Impaired gas exchange related to altered oxygen supply. Risk for infection related to inadequate primary and secondary defenses and chronic disease. Knowledge deficit: COPD related to lack of previous exposure. Inadequate nutrition related to inability to digest or ingest food or to absorb nutrients. Ineffective breathing pattern related to musculoskeletal impairement and decreased energy or fatigue.
Nursing ManagementPlanning Client will maintain patent airway. Client will maintain stable weight. Client will maintain ABG values at baseline. Client will maintain a balanced intake and output. Client will be able to effectively clear secretions. Client will be able to demonstrate diaphragmatic and pursed-lip breathing. Client will be able to demonstrate relaxation techniques to control breathing. Client will maintain a respiratory rate between 16 and 25 breaths/min. Client will be able to list significant and reportable signs and symptoms.
Nursing ManagementIntervention Pulmonary Rehabilitation pulmonary rehabilitation includes 20 to 30 minutes of exercise 3 to 5 times a week Smoking Cessation Nutrition reduce carbohydrates to only 50% of the diet (the breakdown of carbohydrates has been shown to increase the CO₂ load Breathing Retraining diaphragmatic breathing and pursed-lip breathing Chest Physiotherapy Pulmonary Hygiene oral fluids of 4 t 6 quarts a day Medication Inhaled medications are only as effective as the delivery Exercise Home Oxygen therapy