Chronic Obstructive Pulmonary Disease

COPD is a term that refers to a group of conditions characterized by continued increase in resistance to expiratory airflow. It includes chronic bronchitis and pulmonary emphysema. Fourth leading cause of death in US and throughout the world.

 Definition

• Chronic inflammation of the lower respiratory tract characterized by excessive mucous secretion, cough and dyspnea associated with recurring infection of lower respiratory tract.
• Complex lung disease characterized by destruction of the alveoli, enlargement of distal air spaces and breakdown of alveolar walls. There is slowly progressive deterioration of lung function for many years before the development of illness. 

 Pathophysiology

Bronchitis

 Hyperplasia (increased number) and hypertrophy (increased size) of the goblet cells (mucous gland) of the air way                     

• Increase in secretion of mucus and infiltration of the air way walls with inflammatory cells

• Followed by scarring and remodeling that thickens the walls resulting in narrowing of the small airway

• Further progression leads to metaplasia abnormal changes in the tissues and fibrosis further thickening and scarring of the lower airway resulting in limitation of airflow

Emphysema

• Emphysema is defined histologically as the enlargement of the air spaces distal to the terminal bronchioles with destruction of their walls
• The enlarged air sacs alveoli of the lungs reduces the surface area available for the movement of gases during respiration .ultimately leads to dyspnea
• Signs and Symptoms
• Cough
• Sputum (mucus) production
• Shortness of breath, especially with exercise
• Wheezing (a whistling sound when you breathe)
• Chest tightness

Etiology

• Smoking : 25%of smokers are at risk
• Occupational pollutants: Cadmium and silica are contributing factor.  Coal worker and asbestos workers are at increased risk for concomitant pneumoconiosis, emphysema, asbestosis
• Air pollution: Biomass fuel
• Genetics: Deficiency in alpha I antitrypsin
• Other factors:Increasing age,  male, allergy repeated air way infection

Diagnostic Tests 

• A medical history, physical exam
• Breathing Tests
• Spirometry: test of lung functions
• Chest X-Ray  shows emphysema and over expanded lungs
• Arterial blood gas shows hypoxemia and respiratory acidosis
• Pulmonary function test shows decreased airflow rates while exhaling and over expanded lungs

 Management

• Smoking cessation
• Occupational change
• Pharmacotherapy:

              Bronchodilators.

              B2 agonist, salbutamol, bambuterol,

             M3 muscarinic antagonist (anticholinergic) ipratropium, tiotropium

             Cromones

             Leukotriene antagonists

             Xanthines: Theophyline

             Corticosteroids:Beclomethasone & fluticasone.

             TNF antagonists : (Tumor Necrosis Factor Antagonists)-Infliximab   

• Supplemental Oxygen:
• Vaccinate against influenza, pneumococcus.
• Pulmonary rehabilitation: Disease management, counseling and exercise.
• Diet: Recent French study shows that Mediterranean diet “halves the risk of serious lung disease like emphysema and bronchitis.
• Surgical Management: Lung transplant is sometimes performed for severe cases.

 Nursing Assessment:

• Determine smoking history, exposure history, positive family history of respiratory disease, onset of dyspnea
• Note amount colour consistency of sputum
• Inspect for use of accessory muscles of respiration and use of abdominal muscle during expiration
• Auscultate for decreased or absent breath sounds, crackles, decreased heart sound

Nursing Diagnoses and Management

1.      Ineffective airway clearance related to broncho constriction, increased mucus production

  Goal: Improve airway clearance

• Eliminate all pulmonary irritants, particularly cigarette smoking
• Keep patients room as dust free as possible
• Administer bronchodilators to control bronchospasm and assist with raising sputum
• Use postural drainage positions to aid in clearance of secretion
• Encourage high level of fluid intake 8-10 glasses daily
• Give steam inhalation
• Avoid dairy products as it will increase sputum production

2.      Ineffective breathing pattern related to chronic airflow limitation.

Goal: Improve breathing pattern

• Teach deep breathing exercise to strengthen diaphragm and muscles of expiration
• Use pursed lip breathing during dyspnea to control rate and depth of respiration
• Provide a comfortable position
• Discuss and demonstrate relaxation exercise

3.      Impaired gas exchange related to chronic pulmonary obstruction

Goal: improve gas exchange

• watch for breathlessness , aggressiveness, anxiety central cyanosis
• Review ABG
• Give low flow oxygen to control hypoxemia as low oxygen level act as stimulus for respiration in COPD
• Prepare for mechanical ventilation if respiratory failure and rapid co2 retention occur

4.      Altered nutrition less than body requirements related to increased work if breathing, air swallowing

Goal: Improve nutrition

• Encourage small frequent meals
• Avoid food producing abdominal discomfort
• Employ good oral hygiene before meal to improve taste sensation
• Give supplemental oxygen while eating
• Monitor body weight

 5. Activity intolerance related to compromised pulmonary function resulting in shortness of breath and fatigue

Goal: Increase activity tolerance

• Encourage the patient to carry out regular exercise program to increase physical endurance
• Warn to avoid over fatigue to reduce respiratory distress
• Advise to adjust activities according to individual fatigue patterns
• Advise to try to cope with emotional stress positively as possible

Education

• Advice to stop smoking and smoke filled rooms
• Advise to avoid sweeping, dusting, exposure to paint, bleaches and other respiratory irritants
• Warn the patient to avoid extreme hot and cold weather to avoid aggravating bronchial obstruction and sputum production
• Encourage to take shower in warm water
• Warn to avoid exposure to persons with respiratory infection
• Advise to avoid crowds and areas with poor ventilation
• Teach how to recognize and report evidence of respiratory infection like chest pain, change in colour, consistency and amount of sputum, wheezing, shortness of breath
• Instruct to take prescribed antimicrobial at first sign of infection
• Advice maintain an adequate fluid intake
• Teach postural drainage exercise. Stay in each position 5-15 minute and use controlled cough after each position
• Teach use of metered dose inhaler properly. Breathe out normally. Open mouth and place inhaler 2-4 inches in front of the mouth .inhale slowly and activate cartridge to release spray. Pause holding breath for about 10 second, and exhale slowly
• Encourage high protein diet with adequate vitamin mineral and fluid intake
• Avoid excessive hot and cold food
• Avoid hard to chew and gas forming foods
• Encourage five to six small meals daily
• Suggest rest period before and after meals 

Recommendations Based on Clinical Evidence

1. Level of dyspnea should be measured using a quantitative scale such as visual

      analogue numeric rating scale or medical research council dyspnea scale

•  not troubled by breathlessness except on strenuous exercise
• short of breath when hurrying up or walking up a slight hill
• walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace
• stop for breath after about 100m or a few minute on the level
• too breathless to leave the house or breathless when dressing or undressing

1. For patient who have history of smoking and are over the age of 40, nurses should advocate for spirometric testing to establish early diagnosis.
2. Annual influenza vaccination should be recommended
3. COPD patient should receive a pneumococcal vaccine at least once in their life (high risk patient every 5-10 years)
4.  Organizations must institutionalize dyspnea as the 6th vital sign