Chronic Obstructive Pulmonary Disease (COPD) Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Transcription

1 Chronic Obstructive Pulmonary Disease () Copyright 2014 by Mosby, an imprint of Elsevier Inc.

2 Description Airflow limitation not fully reversible progressive Abnormal inflammatory response of lungs Includes Chronic bronchitis Emphysema

3 Etiology Risk factors Cigarette smoking Occupational chemicals and dust Air pollution Infection Heredity Aging

4 Pathophysiology Defining features Irreversible airflow limitations during forced exhalation due to loss of elastic recoil Airflow obstruction due to mucous hypersecretion, mucosal edema, and bronchospasm

5 Pathophysiology

6 Clinical Manifestations Develops slowly Diagnosis Cough* Sputum production Dyspnea Exposure to risk factors

7 Clinical Manifestations Dyspnea exertion (early) stages/ rest (late) Chest breathing accessory and intercostal muscles Inefficient breathing Chest tightness with activity

8 Clinical Manifestations underweight with adequate caloric intake Chronic fatigue What physical finding will you find on exam?

9 Case Study G.S., a 77-year-old man at the hospital shortness of breath morning cough swelling in his lower extremities. difficulty breathing when he walks short distances ie. bathroom.

10 Case Study istockphoto/thinkstock G.S. subjective c/o: sleeps in a recliner to make it easier to breathe feels shoes are tight at the end of the day He is placed on oxygen at 2 liters/minute via nasal cannula.

11 Case Study Dx: mild to moderate Hx: smoked a pack of cigarettes/day for 30 years. heart disease and GERD. istockphoto/thinkstock Discuss questions: How does his history contribute to his diagnosis? Why does he experience swollen ankles? What other complications is he at risk for?

12 Cor Pulmonale Hypertrophy of right side of heart Result of pulmonary hypertension Late manifestation Eventually causes right-sided heart failure

13 Pathophysiology of Cor Pulmonale

14 Cor Pulmonale Dyspnea Distended neck veins Hepatomegaly with right upper quadrant tenderness Peripheral edema Weight gain

15 Cor Pulmonale Diagnostic studies ECG Chest x-ray Right-sided cardiac catheterization Echocardiogram BNP levels

16 Exacerbations Signaled by change in usual Dyspnea Cough Sputum

17 Case Study G.S. shares that he has experienced attacks like this in the past year, but this one was a bit worse. He states that he and his wife had visited their daughter and her 3 kids who were sick with colds. istockphoto/thinkstock What is the likely cause of this exacerbation? What would you anticipate in regard to treatment? What is G.S. at risk for with exacerbation?

18 Exacerbations poorer outcomes Primary causes Bacterial and viral infections Signs of severity Use of accessory muscles Central cyanosis

19 Exacerbations Treatment Short-acting bronchodilators Corticosteroids Antibiotics Supplemental oxygen therapy

20 Acute Respiratory Failure Caused by Exacerbations Discontinuing bronchodilator or corticosteroid medication Overuse of sedatives, benzodiazepines, and opioids Surgery or severe, painful illness involving chest or abdomen

21 Depression and Anxiety experience many losses. If patient becomes anxious because of dyspnea, teach pursed lip breathing.

22 Diagnostic Studies Diagnosis confirmed by spirometry Reduced FEV1/FVC ratio Increased residual volume

23 Diagnostic Studies Chest x-ray History and physical Assessment Test (CAT) Modified Medical Research Council (mmrc) Dyspnea Scale 6-minute walk test to determine O 2 desaturation in the blood with exercise BODE index

24 Diagnostic Studies ABG typical findings in later stages Low PaO2 PaCO2 ph Bicarbonate level found in late stages of

25 Case Study G.S. s arterial blood gases show a slight PaO2 and PaCO2, and his chest x-ray shows flattening of his diaphragm. O 2 saturation is 88%. His FEV1/FVC is 65%, and he states he is having difficulty completing ADLs without frequent rest periods. istockphoto/thinkstock What interventions would be of benefit to G.S. at this time?

26 Collaborative Care Global Initiative for Chronic Obstructive Lung Disease (GOLD) American College of Physicians clinical guidelines Smoking cessation Biggest impact in risk reduction Accelerated decline in pulmonary function slows to almost nonsmoking levels.

27 Case Study istockphoto/thinkstock G.S. is given a short-acting bronchodilator via nebulizer. He will also be given a SABA inhaler and an ICS for home use. He is started on azithromycin (Zithromax). Why was a nebulizer used in the hospital? What is the rationale for the SABA? How should he use his ICS? Will G.S. need oxygen for home use?

28 Collaborative Care O2 therapy is used to Keep O 2 saturation > 90% during rest, sleep, and exertion, or PaO 2 greater than 60 mm Hg.

29 Collaborative Care Long-term O2 therapy improves Survival Exercise capacity Cognitive performance Sleep in hypoxemic patients

30 Collaborative Care O2 delivery systems: high- or low-flow. Low-flow is most common. Low-flow is mixed with room air, and delivery is less precise than high-flow. High-flow fixed concentration Venturi mask Humidification

31 Collaborative Care Complications of oxygen therapy Combustion CO2 narcosis O2 toxicity Absorption atelectasis Infection

32 Collaborative Care Long-term O2 therapy (LTOT) at home improves Prognosis Mental acuity Exercise intolerance

33 Collaborative Care Respiratory and physical therapy Breathing retraining Effective coughing Chest physiotherapy Percussion Vibration Postural drainage

34 Collaborative Care Respiratory and physical therapy Airway clearance devices High-frequency chest wall oscillation The Vest

35 Case Study G.S. is going to be discharged to home. He is given an Acapella device to assist him with expulsion of mucus. His wife is present, and you begin to teach them about home care. istockphoto/thinkstock What will your teaching plan include?

36 Collaborative Care Nutritional therapy Weight loss and malnutrition are common. Why? Tx: Rest at least 30 minutes A.C. Bronchodilator Other interventions?

37 Collaborative Care Surgical therapy Lung volume reduction surgery Bullectomy Lung transplantation Single lung Most common because of donor shortages Prolongs life Improves functional capacity Enhances quality of life

38 Collaborative Care Minimally invasive treatment Airway bypass Bronchoscopic procedure Used to reduce hyperinflation

39 Case Study G.S. appears fatigued and has difficulty answering the many questions he is asked. His wife expresses concern that he has not been sleeping well. istockphoto/thinkstock What areas could be addressed with G.S. in regard to health promotion? How can his wife and family help?

40 Case Study G.S. comes into the clinic in one week for follow-up. He is breathing much easier and states that he is able to perform ADLs with less distress. istockphoto/thinkstock He and his wife ask about how to prevent further breathing difficulties?

41 Audience Response Question The nurse reviews the arterial blood gases of a patient. Which result would indicate the patient has later stage? a. ph 7.32, PaCO 2 58 mm Hg, PaO 2 60 mm Hg, HCO 3 30 meq/l b. ph 7.30, PaCO 2 45 mm Hg, PaO 2 55 mm Hg, HCO 3 18 meq/l c. ph 7.40, PaCO 2 40 mm Hg, PaO 2 70 mm Hg, HCO 3 25 meq/l d. ph 7.52, PaCO 2 30 mm Hg, PaO 2 80 mm Hg, HCO 3 35 meq/l