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

Emphysema: Clinical Manifestations 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 Pulmonary function  residual volume,  lung capacity, DECREASED FEV1, 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

Asthma: Pathophysiology 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: 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 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 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 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

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