Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a disease characterized by airflow limitation that is not fully reversible. Airflow limitation is usually progressive and associated with an inflammatory response in the lungs stimulated by irritants. COPD includes chronic bronchitis and pulmonary emphysema. Although sometimes included in COPD, asthma is a reversible disorder. Chronic bronchitis is chronic inflammation of the lower airways characterized by excessive secretion of mucus, hypertrophy of mucous glands, and recurring infection, progressing to narrowing and obstruction of airflow. Emphysema is the enlargement of air spaces distal to the terminal bronchioles, with breakdown of alveolar walls and loss of elastic recoil of the lungs. The two conditions may overlap, resulting in subsequent derangement of airway dynamics (e.g. obstruction to airflow). In pulmonary emphysema, lung function progressively deteriorates for many years before the illness becomes apparent. The most common cause of COPD is cigarette smoking. Air pollution, occupational exposures, allergens, and infections may also act as irritants. Alpha1-antitrypsin deficiency is an infrequent cause. Complications include respiratory failure, pneumonia or other overwhelming respiratory infection, right heart failure (cor pulmonale), arrhythmias, and depression. Assessment 1. Signs and symptoms of chronic bronchitis (insidious set): a. Productive cough lasting at least 3 months during a year for 2 successive years b. Thick, gelatinous sputum (greater amounts produced during superimposed infections) c. Dyspnea and wheezing as disease progresses 2. Signs and symptoms of emphysema (gradual in onset and steadily progressive): a. Dyspnea, decreased exercise tolerance b. Cough (may be minimal with mild sputum production, except with respiratory infection) c. Increased anteroposterior diameter of chest (barrel chest) with diaphragm flattening (due to air trapping EMERGENCY ALERT Recognize early manifestations of respiratory infection-increased dyspnea and fatigue; changes in color, amount and character of sputum; adventitious breath sounds, low-grade fever; nervousness; irritability-so treatment can be started early to prevent respiratory failure.

Diagnostic Evaluation 1. Pulmonary function tests, to demonstrate airflow obstructionreduced forced expiratory volume in 1 second (FEV1), FEV1 to forced vital capacity ratio; increased residual volume to total lung capacity (TLC) ratio, possibly increased TLC 2. Chest X-rays to detect hyperinflation, flattened diaphragm, increased retrosternal space, decreased vascular markings, possible bullae (all in late stages)
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3. Arterial blood gases, to detect decreased arterial oxygen pressure (PaO2), pH and increased arterial carbon dioxide pressure (PaCO2) 4. Alpha1-antitrypsin assay to detect this specific cause of emphysema 5. Sputum smears and cultures to identify pathogens Collaborative Management Therapeutic and Surgical Interventions 1. Smoking cessation to stop the progression and preserve lung capacity 2. Low-flow oxygen to correct severe hypoxemia in a controlled manner and minimize carbon dioxide retention. EMERGENCY ALERT Normally, carbon dioxide levels in the blood stimulate respiration. However, in patients with COPD, chronically elevated carbon dioxide impairs the mechanism, so low oxygen levels in the blood stimulate respiration. Giving a high oxygen concentration may remove the hypoxic drive, leading to hypoventilation, respiratory decompensation, and the development of a worsening respiratory acidosis. 3. 4. 5. 6. 7. Home oxygen therapy, especially at night to prevent nocturnal oxygen desaturation. Pulmonary rehabilitation to reduce symptoms that limit activity. Chest physical therapy, including postural drainage and breathing retraining. Lung volume reduction surgery has been beneficial for some with emphysema. Lung transplant in severe cases of alpha1-antitrypsin deficiency.

Pharmacologic Interventions Drugs Used for COPD DRUG/ACTION Beta2-adrenergic agonists Anticholinergics

Methylxanthines

Corticosteroids

ADVERSE REACTIONS/IMPLICATIONS Sympathomimetic effects: nervousness, restlessness, tachycardia, insomnia, nausea, dizziness, cardiac dysrhythmias, sweating, flushing. Anticholinergic and sympathomimetic effects (usually mild): nervousness, dizziness, headache, blurred vision, cough, nausea, hoarseness, dry mouth. Adverse effects with serum level 20g/mL: nausea, vomiting, diarrhea, headache, insomnia, and irritability, and restlessness, loss of appetite, tachycardia, and ventricular dysrhythmias possible. Note: Many drugs, cigarette smoking, and highprotein diet can affect serum concentration. Oral and pharyngeal irritation and candidiasis are
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usually only adverse effects with respiratory inhalation; Cushings syndrome possible with longterm, high-dose use. 1. Bronchodilators to reduce dyspnea and control bronchospasm delivered by metered-dose inhalers, other handheld devices, or nebulization. a. Anticholinergics, such as ipratropium and tiotropium. DRUG ALERT Anticholinergic agents may worsen narrow-angle glaucoma, prostatic hypertrophy, and bladder neck obstruction.

2. 3. 4. 5.

b. Short-acting beta agonists, such as albuterol and pirbuterol. c. Long-acting beta agonists, such as salmeterol and formoterol. d. Methylxanthines, such as theophylline, given orally, usually as sustained-release form for chronic maintenance therapy (less commonly used). Inhaled corticosteroids may be useful for some with severe airflow limitation and frequent exacerbations. Corticosteroids by mouth for I.V. in acute exacerbations Antimicrobials to control secondary bacterial infections in the bronchial tree, thus clearing the airways Alpha1-antitrypsin replacement delivered by I.V. infusion

Nursing Diagnoses Activity intolerance Anxiety Disturbed sleep pattern Health-seeking behaviors (specify) Imbalanced nutrition: Less than body requirements Impaired gas exchange Impaired social interaction Ineffective airway clearance Ineffective breathing pattern Ineffective therapeutic regimen management Risk for infection Nursing Interventions Monitoring 1. Monitor for adverse effects of bronchodilatorstremulousnes, tachycardia, cardiac arrhythmias, central nervous system stimulation, hypertension.

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2. Monitor condition after administration of aerosol bronchodilators to assess for improved aeration, reduced adventitious breath sounds, reduced dyspnea. 3. Monitor serum theophylline level, as ordered, to ensure therapeutic level and prevent toxicity. 4. Monitor oxygen saturation at rest and with activity. EMERGENCY ALERT Watch for and report excessive somnolence, restlessness, aggressiveness, anxiety, or confusion; central cyanosis; and shortness of breathe at rest, which frequently is caused by acute respiratory insufficiency and may signal respiratory failure. Supportive Care 1. Eliminate all pulmonary irritants, particularly cigarette smoke. Smoking cessation usually reduces pulmonary irritation, sputum production, and cough. Keep the patients room as dust-free as possible. 2. Use postural drainage positions to help clear secretions responsible for airway obstruction. 3. Teach controlled coughing. 4. Keep secretions liquid. a. Encourage high level of fluid intake (8 to 10 glasses; 2 to 2.5 L daily) within level of cardiac reserve. b. Give inhalations of nebulized saline to humidify bronchial tree and liquefy sputum. Add moisture (humidifier, vaporizer) to indoor air. c. Avoid dairy products if these increase sputum production. 5. Encourage the patient to assume comfortable position to decrease dyspnea. 6. Instruct and supervise patients breathing retraining exercises. Teach lower costal, diaphragmatic, and abdominal breathing, using a slow and relaxed breathing pattern to reduce respiratory rate and decrease work of breathing. 7. Use pursed lip breathing at intervals and during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination. 8. Discuss and demonstrate relaxation exercises to reduce stress, tension, and anxiety. 9. Maintain the patients nutritional status: a. Obtain nutritional history, weight, and anthropometric measurements. b. Encourage frequent small meals if the patient is dyspneic; even a small increase in abdominal contents may press on diaphragm and impede breathing. c. Offer liquid nutritional supplements to improve caloric intake and counteract weight loss. d. Avoid foods producing abdominal discomfort. e. Advise good oral hygiene before meals to sharpen taste sensations. f. Encourage pursed-lip breathing between bites (or give supplemental oxygen, as directed) if the patient is very short of breath; allow rest after meals. g. Monitor body weight. 10. Reemphasize the importance of graded exercise and physical conditioning programs (enhances delivery of oxygen to tissues; allows a higher level of functioning with greater comfort).
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11. Encourage use of portable oxygen system for ambulation for patients with hypoxemia and marked disability. 12. Encourage the patient to carry out regular exercise program to increase physical endurance. 13. Train the patient in energy conservation techniques. 14. Assess the patient for reactive behaviors (anger, depression, and acceptance). Allow the patient to express feelings and retain (within a controlled degree) the mechanisms of denial and repression. 15. Be aware that sexual dysfunction is common in patients with COPD; encourage alternative displays of affection to loved one. Education and Health Maintenance 1. Review with the patient the objectives of treatment and nursing management. Work with the patient to set goals (i.e. stair climbing, return to work, and so forth). 2. Advise the patient to avoid respiratory irritants. Suggest that a high efficiency particulate air filter may have some benefit. 3. Warn patient to stay out of extremely hot or cold weather (and to avoid showering in very hot water) to avoid aggravating bronchial obstruction and sputum production. 4. Instruct the patient to humidify indoor air in winter; maintain 30% to 50% humidity for optimal mucociliary function. 5. Warn the patient to avoid persons with respiratory infections, and to avoid crowds and areas with poor ventilation. 6. Stress the importance of obtaining influenza and pneumococcal vaccines to guard against these respiratory infections. 7. Teach the patient how to recognize and report evidence of respiratory infection promptlychest pain, changes in character of sputum (amount, color, or consistency), increasing difficulty in raising sputum, increasing coughing and wheezing, increasing shortness of breath. 8. Tell the patient to use bronchodilators only as directed, and advise how to use metered-dose inhaler properly to maximize aerosol deposition in the bronchial tree. If the patient cannot use inhaler effectively, suggest using a spacer device. COMMUNITY CARE CONSIDERATIONS Early in the patients course, the issue of living will, advanced directives, and resuscitation status need to be addressed. It is better to have these discussions with the patient before crisis situations. Suggest a pulmonary rehabilitation program that is offered in most communities. Benefits include decrease in hospital admission, decreased length of stay, and increase in the patients sense of well-being. Contact local hospitals or the American Lung Association.
Nettina, Sandra M. "Diseases and Disorders: Chronic Obstructive Pulmonary Disease." LIPPINCOTT MANUAL OF NURSING PRACTICE Handbook. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2006. 210-17. Print.

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