Management of Patients With Chronic Pulmonary Disease

COPD: Chronic Obstructive Pulmonary Disease A disease state characterized by airflow limitation that is not full reversible (GOLD). COPD is the currently is 4 th leading cause of death and the 12 th leading cause of disability. COPD includes diseases that cause airflow obstruction (emphysema, chronic bronchitis) or a combination of these disorders. Asthma is now considered a separate disorder but can coexist with COPD.

Pathophysiology of COPD Airflow limitation is progressive and is associated with abnormal inflammatory response of the lungs to noxious agents. Inflammatory response occurs throughout the airways, lung parenchyma, and pulmonary vasculature. Scar tissue and narrowing occurs in airways. Substances activated by chronic inflammation damage the parenchyma. Inflammatory response causes changes in pulmonary vasculature.

Chronic Bronchitis The presence of a cough and sputum production for at least 3 months in each of 2 consecutive years. Irritation of airways results in inflammation and hypersecretion of mucous. Mucous-secreting glands and goblet cells increase in number. Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucous may plug airways. Alveoli become damaged, fibrosed, and alveolar macrophage function diminishes. The patient is more susceptible to respiratory infections.

Pathophysiology of Chronic Bronchitis

Emphysema: Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli. Decreased alveolar surface area causes an increase in “dead space” and impaired oxygen diffusion. Reduction of the pulmonary capillary bed increases pulmonary vascular resistance and pulmonary artery pressures. Hypoxemia result of these pathologic changes. Increased pulmonary artery pressure may cause right- sided heart failure (cor pulmonale).

Changes in Alveolar Structure with Emphysema

Risk Factors for COPD Tobacco smoke causes 80-90% of COPD cases! Passive smoking Occupational exposure Air pollution Genetic abnormalities (2% of cases) – Alpha 1 -antitrypsin deficiency ( enzyme inhibitor that protect the lung parenchyma from injury)

Clinical Manifestation 3 primary symptoms: 1.Chronic cough 2.Sputum production 3.Dyspnea on exertion Wt loss Barrel chest (A-P diameter/ Transverse diameter : 2/1) Retraction in the supraclavicular area on inspiration Shrug shoulder Abdominal muscle contraction on inspiration (paradox respiration).

Normal Chest Wall and Chest Wall Changes with Emphysema

Typical Posture of a Person with COPD

Medical Management Risk reduction Pharmacologic therapy Management of exacerbation O2 therapy Surgical management Pulmonary rehabilitation

Nursing Process: The Care of Patients with COPD- Assessment Health history Inspection and examination findings Review of diagnostic tests

Nursing Process: The Care of Patients with COPD- Diagnoses Impaired gas exchange Impaired airway clearance Ineffective breathing pattern Activity intolerance Deficient knowledge Ineffective coping

Collaborative Problems Respiratory insufficiency or failure Atelectasis Pulmonary infection Pneumonia Pneumothorax Pulmonary hypertension

Nursing Process: The Care of Patients with COPD- Planning Smoking cessation Improved activity tolerance Maximal self-management Improved coping ability Adherence to therapeutic regimen and home care Absence of complications

Improving Gas Exchange Proper administration of bronchodilators and corticosteroids Reduction of pulmonary irritants Directed coughing, “huff” coughing Chest physiotherapy Breathing exercises to reduce air trapping – diaphragmatic breathing – pursed lip breathing Use of supplemental oxygen

Improving Activity Tolerance Focus on rehabilitation activities to improve ADLs and promote independence. Pacing of activities Exercise training Walking aides Utilization of a collaborative approach

Other Interventions Set realistic goals Avoid extreme temperatures Enhancement of coping strategies Monitor for and management of potential complications

Patient Teaching Disease process Medications Procedures When and how to seek help Prevention of infections Avoidance of irritants; indoor and outdoor pollution, and occupational exposure Lifestyle changes, including cessation of smoking