Running Head: RESPIRATORY CARE MODALITIES AND MANAGEMENT 1

Respiratory Care Modalities and Management of patients with COPD.

Jessica Brown

Nazareth College
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Case Study, Chapters 21 and 24, Respiratory Care Modalities and Management of
patients with COPD.

This case study is worth 5% of your grade. Each student will complete this case
study independently. I request that it is typed, double-spaced and your references
are in APA format. NO EXCEPTIONS. DUE DATE: 3/29/17 at the beginning of
class.

Bill McDonald, 65 years of age, is a male patient diagnosed with chronic obstructive

pulmonary disease (COPD). He is going to be discharged with home oxygen at 2 L/min

per nasal cannula. According to Medicare guidelines, the patient falls into the group 1

patient category, the patient’s O2 saturation on room air was less than 88% and his PaO2

was less than 55 mm Hg, which was obtained from an arterial blood gas (ABG) at room

air. The physician completed the script for the home oxygen therapy according to

Medicare guidelines. The information that needed to be included on the script was the

documented diagnosis, the prescribed liter flow, the frequency of use in hours per day,

and the number of months in duration. The results of the pulse oximetry and the ABG

were also included in the script to justify the need for the home oxygen therapy. The

nurse needs to make arrangements with the social worker to obtain an agency to supply

the oxygen equipment needed and to provide follow-up on a regular basis. The supplier

makes arrangements to deliver an oxygen concentrator and portable tanks or concentrated

oxygen and oxygen regulators, and needed supplies, including 50 feet of tubing, and

nasal cannulas.
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A.What home care considerations need to be made before the patient is discharged and

what considerations need to be made once the patient arrives home?

There are many home care considerations that need to be addressed before our

patient can be discharged. These include having the company that will be supplying the

oxygen tanks and other equipment make arrangements with the patient and family to

deliver and set up the home oxygen supplies and equipment before the patient is released

(American Thoracic Society). It is essential that the supplier communicates that this has

been done to the nurse as well as the social worker managing the patient’s case

(American Thoracic Society). If the physician determines that home health nurse visits

are required, then these arrangements will also need to be made before discharging the

patient (Hinkle & Cheever, 2014, 498). It is important that the patient’s home is free of

clutter and messes so there is room for the patient to have his equipment in the areas that

he frequents, and also to reduce the risk of the 50 feet of tubing getting caught on things

or tripping when he is using his nasal cannula. Once the patient is back at home, the

oxygen supplier should be present to instruct the patient and family on safe

administration of the oxygen and use of the equipment. If a home health nurse will be

making visits it may be a good idea for them to also be present at this time so that the

patient, family, and nurse will all be on the same page as far as equipment use and patient

goals (Hinkle & Cheever, 2014, 498). Often times the supplier has a respiratory therapist

make the home visit so they will be able to assess the patient’s respiratory status once he

is hooked up to the equipment to ensure that it is working properly. The supplier must

leave their contact information with the patient and family in case they need to be
RESPIRATORY CARE MODALITIES AND MANAGEMENT 4

reached at any point in time (American Thoracic Society).

B. What patient and family education must the nurse provide in regard to home oxygen

therapy?

It is important to explain that the oxygen concentrator draws in room air that

contains 21% oxygen (Hinkle & Cheever, 2014, 494) in it and filters it and concentrates

it to deliver 100% oxygen at the prescribed amount. The storage is limited, so the

concentrator continuously draws in air, concentrates it, and then releases it into the

oxygen tubing. The concentrator runs on electricity, and the compressor component tends

to make it loud (American Thoracic Society). It is necessary that the concentrator is away

from walls or furniture so it can consume a sufficient amount of air to meet the needs of

the patient. There are filters in the concentrator that periodically need to be cleaned

and/or changed as well as other equipment maintenance; the oxygen supplier should

inform the patient and family members how to perform these maintenance tasks

(American Thoracic Society). The supplier will also take care of providing tubing and

nasal cannulas and tell you how often to replace them. The nasal cannula may be wiped

off whenever there is visible dirt or daily with soap and water and dried, and the tubing

should be changed every 3-6 months if you have not been sick over that period of time

(COPD Foundation). Never place the oxygen equipment near an open flame or device

that produces heat, such as a water heater, furnace, or fireplace, and post “No Smoking

Oxygen in Use” signs on the front door and back door of your home (Hinkle & Cheever,

2014, 499). Never smoke around the oxygen or equipment (Hinkle & Cheever, 2014,

499). Oxygen tanks require the use of a regulator that is attached using a wrench. The

supplier will show you how to access and stop using a tank. The portable tanks must stay
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secured and upright. If a tank is punctured accidentally the contents are under such high

pressure that it can become airborne and act as a torpedo, so make sure that tanks that are

not in use are upright and secured to a wall (American Thoracic Society). Be sure to turn

off portable tanks when they are not in use and the gauge on the tank that will tell you

how full or empty the tank may be (COPD Foundation). In the case of a power outage

you will need to use portable oxygen cylinders as the backup unless you have a home

generator, typically the supplier will have a large portable tank just for this purpose

(American Thoracic Society). Never administer more oxygen than what your physician

has prescribed unless the physician gives you specific instructions to adjust the setting

because there are negative side effects associated with too much oxygen consumption

(Hinkle & Cheever, 2014, 495). Demonstrate how to read an oxygen gauge and adjust it

and have the patient/family return the demonstration to ensure effective teaching

strategies (Hinkle & Cheever, 2014, 499). If you travel, the smaller portable tanks will

allow you to be able to have oxygen as needed while the patient is on the go (American

Thoracic Society). The supplier will instruct you on how many hours worth of oxygen are

contained in the tanks so that you can determine how many you need to take for the time

you are traveling (COPD Foundation). If you are planning a trip and want to fly, for

instance, then contact the airport at least two weeks ahead of time so arrangements may

be made in regards to the provision of oxygen and what their specific rules are in regards

to bringing oxygen onboard a plane (Hinkle & Cheever, 2014, 499). Always have a copy

of your physician’s script and the contact information for your oxygen supplier, and be

sure to check with your travel agent if applicable because there are some traveling groups

that will make special arrangements for customers who require oxygen and they take care
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of all of the details (COPD Foundation). It is important to drink 2 to 3 liters of fluids each

day, unless contraindicated to keep your mucus membranes moist (Hinkle & Cheever,

2014, 496). Oxygen that is less than 4 liters per minute administered by the nasal cannula

does not require additional humidification other than drinking fluids and humidifying the

environment of the home, but 4 liters or more requires humidification with sterile water

which will need to be obtained from the supplier (Hinkle & Cheever, 2014, 498). The

oxygen passes through the water bottle and picks up moisture before being delivered to

the patient, the water in the bottle bubbles because the air is blowing into it. Be cautious

to never tilt the bottle sideways because water can enter into the oxygen tubing and poses

a risk for aspiration (American Thoracic Society). It is important to inspect the skin of the

face and around the ear and nose for signs of redness, which is an indicator that the nasal

cannula tubing is too tight and placing too much pressure on the skin. The nurse should

demonstrate how to inspect the skin and how to pad the nasal cannula to decrease

pressure on the skin and have the patient/family return the demonstration (Hinkle &

Cheever, 2014, 499). It is important to understand the proper way to apply the nasal

cannula. Demonstrate how to properly apply and remove the nasal cannula and have the

patient and family return the demonstration (Hinkle & Cheever, 2014, 499).

C. What pharmacologic therapy do you anticipate will be prescribed for this patient?

Describe drug classes, side effects and nursing considerations regarding these therapies.

Typically COPD patients are treated with a combination of steroids,

bronchodilators, and oxygen therapy as described above. Sometimes mucolytics are also

used to help break up thick secretions which may be causing additional difficulty

breathing and antibiotics are used if there is a bacterial infection present. The types of
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bronchodilators used to treat COPD include:

● Beta2-agonists

● Anticholinergics

● Corticosteroids

(American Thoracic Society). The American Thoracic Society describes beta2-agonists

based upon time of release, route, and side effects. Inhaled beta2-agonists can be fast-

acting (3 to 5 minutes), or slow-acting (20 minutes). These medications can also be short-

or long-lasting. Short lasting beta2-agonists include albuterol, pirbuterol, salbutamol, and

terbutaline last for 4-6 hours, while long-lasting beta2-agonists including salmeterol and

formoterol can last up to 12 hours. The drugs Indacaterol and vilanterol are meant to last

up to 24 hours. Many of these drugs are available in both inhaled and pill form, but pill

form can often cause more side effects than the inhaled form. Beta2-agonists that are fast-

acting are also known as “reliever medicines” because they bring quick relief for

breathlessness, but do not last long enough to produce all day relief. Using your reliever

medication before an activity that you know makes your breathing worse (exertion) may

help lessen or prevent your breathing difficulty. Long-lasting beta2-agonists are taken

every 12 to 24 hours, providing more convenient treatment of COPD. Common side

effects when taking beta2-agonists are increased heart rate, shakiness, and cramping of

the hands, legs, and feet. Often this combination of fast heart rate and shakiness can cause

anxiety and exacerbate COPD symptoms. This typically only happens when the medicine

is overused. These side effects can last anywhere from a few minutes after taking the

medicine, and may totally go away after a few days of regular use. If the side effects do

not go away, talk to your health care provider, who may stop or reduce the dose, or
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change to another type of bronchodilator (American Thoracic Society).

Anticholinergic bronchodilators are inhaled medicines. As with beta2-agonists,

they can also be short- or long-lasting. The short-lasting form, ipatropium, works in about

15 minutes and lasts for 6–8 hours, and is usually taken 4x a day. The long-lasting forms

take about 20 minutes to begin working and last 24 hours (tiotropium, umedclidinum) or

12 hours (aclidinium) Anticholinergics have a longer onset time so they are not to be

used for quick relief of symptoms. Common side effects when taking anticholinergics are

dry mouth and urinary retention. Patients may be given a beta2-agonist in conjunction

with an anticholinergic because the two work better than just one alone to provide quick

acting (emergency) relief and long term relief. This combination gives fast action and

long-lasting relief. Theophylline was a mainstay in COPD treatment until recent years

and is now very rarely seen in the United States because of its severe side effects and

narrow therapeutic range (American Thoracic Society).

Corticosteroids are medications used to reduce inflammation of the airways which

leads to reduced swelling. Corticosteroids are usually taken by inhaler or pill, and often

times an inhaled corticosteroid may be combined with a bronchodilator. Inhaled

corticosteroids can be given in small doses, resulting in fewer adverse side effects. They

do not work quickly, and it may take a week or more before you notice the benefits. Pill

form can act faster than inhaled steroids, but can cause more systemic side effects. Side

effects depend on the dosage, length of use, and route used. The most common side

effects of inhaled corticosteroids are a sore mouth, hoarse voice, and infections in the

throat and mouth. You can reduce these side effects by rinsing your mouth, followed by

spitting after taking an inhaled steroid. Taking corticosteroid pills in high doses, or taking
RESPIRATORY CARE MODALITIES AND MANAGEMENT 9

low doses over a long time, may cause problems including bruising of the skin, weight

gain, weakening of the skin, osteoporosis, cataracts, increased blood sugar, mood

changes, muscle weakness, and edema of the ankles or feet. Patients who use inhaled

corticosteroids have a higher risk of pneumonia (American Thoracic Society).

D. What are the objectives of treatment for this patient?

The objectives of treatment for a patient with COPD are to reduce the long-term

decline of lung function, to prevent and treat exacerbation of symptoms, reduce COPD

related hospitalizations with quality home care and management, decrease mortality,

relieve debilitating dyspnea, improve activity tolerance, and to improve the patient’s

quality of life (American Thoracic Society). It is important that the patient realizes that

COPD is an irreversible and incurable condition, so symptom management, as well as a

thorough understanding of their home care requirements, is the most effective method to

achieve the goals that are listed above (Hinkle & Cheever, 2014, 618).
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REFERENCES

American Thoracic Society Documents Statement on Home Care for Patients with

Respiratory Disorders [PDF file]. (n.d.). Retrieved March 25, 2017, from

https://www.thoracic.org/statements/resources/hcpeeolc/homecare1-22.pdf

Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A

Clinical Practice Guideline Update from the American College of

Physicians, American College of Chest Physicians, American Thoracic Society,

and European Respiratory Society [PDF file]- American Thoracic Society.

(n.d.). Retrieved March 25, 2017, from

https://www.thoracic.org/patients/patient-resources/resources/copd-medicines.pdf

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth's Textbook of

Medical-surgical Nursing, 13th Ed. Lippincott Docucare, 18-month

Access North American Edition. Lippincott Williams & Wilkins.

Information for Medicare Oxygen Patients | Oxygen Therapy | COPD Foundation. (n.d.).

Retrieved March 25, 2017, from

www.copdfoundation.org/What-is-COPD/Living-with-COPD/Oxygen-

Therapy.aspx

Medicines Used to Treat COPD [PDF file]- American Thoracic Society. (n.d.). Retrieved

March 25, 2017, from

www.thoracic.org/patients/patient-resources/resources/copd-medicines.pdf

Patient Education Information Series- Oxygen Therapy [PDF file]- American Thoracic

Society. (n.d.). Retrieved March 25, 2017, from

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https://www.thoracic.org/patients/patient-resources/resources/oxygen-therapy.pdf
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