chronic obstructive pulmonary disease (copd) 8.18 · the nurse reviews the arterial blood gases of...
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Chronic Obstructive Pulmonary Disease (COPD) 8.18.18
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COPD Description
�Airflow limitation not fully reversible• progressive• Abnormal inflammatory response of lungs
� Includes• Chronic bronchitis• Emphysema
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COPDEtiology�Risk factors• Cigarette smoking• Occupational chemicals and dust• Air pollution• Infection • Heredity• Aging
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COPDPathophysiology
�Defining features• Irreversible airflow limitations during forced
exhalation due to loss of elastic recoil• Airflow obstruction due to mucous
hypersecretion, mucosal edema, and bronchospasm
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COPDClinical Manifestations
�Develops slowly�Diagnosis • Cough*• Sputum production• Dyspnea• Exposure to risk factors
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COPDClinical Manifestations
�Dyspnea• exertion (early) stages/ rest (late)• Chest breathing• accessory and intercostal muscles• Inefficient breathing
� Chest tightness with activity
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COPDClinical Manifestations
�underweight with adequate caloric intake
�Chronic fatigue
�What physical finding will you find on exam?
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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.
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Case Study
�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.
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Case Study� Dx: mild to moderate COPD� Hx: smoked a pack of cigarettes/day for
30 years. �heart disease and GERD.
Discuss questions:•How does his history contribute to his diagnosis?•Why does he experience swollen ankles?•What other complications is he at risk for?
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COPDCor Pulmonale
�Hypertrophy of right side of heart• Result of pulmonary hypertension• Late manifestation • Eventually causes right-sided heart failure
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COPDCor Pulmonale
�Dyspnea�Distended neck veins�Hepatomegaly with right upper
quadrant tenderness�Peripheral edema�Weight gain
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COPDCor Pulmonale
�Diagnostic studies• ECG• Chest x-ray• Right-sided cardiac catheterization• Echocardiogram• BNP levels
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COPD Exacerbations
�Signaled by change in usual• Dyspnea• Cough• Sputum
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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.
• 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?
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COPDExacerbations
� poorer outcomes�Primary causes• Bacterial and viral infections
�Signs of severity• Use of accessory muscles• Central cyanosis
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COPD Exacerbations
�Treatment• Short-acting bronchodilators• Corticosteroids• Antibiotics• Supplemental oxygen therapy
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COPDAcute 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
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COPDDepression and Anxiety
� experience many losses.� If patient becomes anxious because of
dyspnea, teach pursed lip breathing.
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COPDDiagnostic Studies
�Diagnosis confirmed by spirometry• Reduced FEV1/FVC ratio• Increased residual volume
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COPDDiagnostic Studies
�Chest x-ray�History and physical�COPD Assessment Test (CAT)�Modified Medical Research Council
(mMRC) Dyspnea Scale�6-minute walk test to determine O2
desaturation in the blood with exercise�BODE index
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COPDDiagnostic Studies
�ABG typical findings in later stages� Low PaO2�↑ PaCO2�↓ pH�↑ Bicarbonate level found in late
stages of COPD
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Case Study
�G.S.’s arterial blood gases show a slight ↓ PaO2 and ↑ PaCO2, and his chest x-ray shows flattening of his diaphragm.
�O2 saturation is 88%.�His FEV1/FVC is 65%, and he states he is having
difficulty completing ADLs without frequent rest periods.
�What interventions would be of benefit to G.S. at this time?
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COPDCollaborative 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.
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Case Study� 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?
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COPDCollaborative Care
�O2 therapy is used to• Keep O2 saturation > 90% during rest, sleep,
and exertion, or• PaO2 greater than 60 mm Hg.
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COPDCollaborative Care
�Long-term O2 therapy improves• Survival• Exercise capacity• Cognitive performance• Sleep in hypoxemic patients
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COPDCollaborative 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
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COPDCollaborative Care
�Complications of oxygen therapy• Combustion • CO2 narcosis• O2 toxicity• Absorption atelectasis• Infection
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COPDCollaborative Care
�Long-term O2 therapy (LTOT) at home improves• Prognosis• Mental acuity• Exercise intolerance
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COPDCollaborative Care
�Respiratory and physical therapy• Breathing retraining• Effective coughing• Chest physiotherapy
�Percussion�Vibration�Postural drainage
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COPDCollaborative Care
�Respiratory and physical therapy• Airway clearance devices• High-frequency chest wall oscillation
�The Vest
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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.
�What will your teaching plan include?
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COPDCollaborative Care
�Nutritional therapy • Weight loss and malnutrition are common. • Why?
• Tx: �Rest at least 30 minutes A.C.�Bronchodilator
�Other interventions?
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COPDCollaborative 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
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COPDCollaborative Care�Minimally invasive treatment• Airway bypass
�Bronchoscopic procedure�Used to reduce hyperinflation
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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.
�What areas could be addressed with G.S. in regard to health promotion?
�How can his wife and family help?
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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.
�He and his wife ask about how to prevent further breathing difficulties?
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The nurse reviews the arterial blood gases of a patient. Which result would indicate the patient has later stage COPD?
a. pH 7.32, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L
b. pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3 18 mEq/L
c. pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3 25 mEq/L
d. pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 35 mEq/L
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Audience Response Question
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