EMPHYSEMA

ANATOMY OF EMPHYSEMA

Emphysema is a lung disease involving damage to the air sacs (alveoli).There is progressive destruction of alveoli and the surrounding tissue that supports the alveoli. With more advanced disease, large air cysts develop where normal lung tissue used to be. Air is trapped in the lungs due to lack of supportive tissue which decreases oxygenation.

DEFINITION

Emphysema is a long-term, progressive disease of the lung(s) and occurs when the alveolar walls are destroyed along with the capillary blood vessels that run within them. This lessens the total area within the lung where blood and air can come together, limiting the potential for oxygen and carbon dioxide transfer.

In early emphysema, there is associated inflammation of the small airways or bronchioles that limits the amount of air that can flow to the alveoli. In more severe emphysema, there is also loss of elasticity in the alveolar walls that have not been destroyed. When the patient breathes out, the alveoli and small airways collapse. This makes it hard for air to get out of the lungs and makes it even harder for new air to enter.

ETIOLOGY

The main cause of emphysema is smoking, which activates inflammatory cells in the lung. This inflammation causes; 1) swelling within the bronchioles, and 2) activation of enzymes called proteases which attack and destroy lung tissue (the alveolar wall structures).

There is a genetic predisposition to emphysema. The relatively rare condition known as alpha 1-antitrypsin deficiency is the genetic deficiency of a chemical that protects the lung from damage by proteases.

Emphysema is also a component of aging. As the lungs get older, the elastic properties decrease, and the tensions that develop can result in small areas of emphysema.

PATHOPHYSIOLOGY

Emphysema is characterized by abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls without obvious fibrosis.

There are 4 types of emphysema:- centriacinar- panacinar- distal acinar- irregular

1) Centriacinar emphysema- The central parts of acini, formed byrespiratory bronchioles are affected while distal alveoli are spared.- In severe centracinar emphysema, distal acinus also become involved.- This emphysema is consequence of cigarette smoking in people who do not have congenital deficiency of alfa-one antitrypsin.

2) Panacinar emphysema- Acini are uniformly enlarged from the level of respiratory bronchiole to the terminal blind alveoli- More commonly occur in lower lung zone.- Occurs in people with alpha-one antitrypsin deficiency.

3) Distal acinar emphysema- Proximal portion of acinus is normal but the distal part is primarily involved.- The emphysema is more striking adjacent to the pleura, along the lobular connective tissue septa, and at margins of lobules.- the characteristic findings are the presence of multiple, continuous, enlarged airspace that range in diameter from less than 0.5mm to more than 2.0cm, sometimes forming cystlike structure called bullae.

IRREGULAR EMPHYSEMA

4) Irregular emphysema- acinus is irregularly involved

PATHOGENESIS

Protease-antiprotease imbalance favors emphysema.

Patient with genetic deficiency of antiprotease alpha-one antitrypsin have tendency to develop pulmonary emphysema and is compounded by smoking.

Alpha-one antitrypsin is normally present in serum, tissue fluids and macrophage which is major inhibitor of protease ( elastase ) secreted by neutrophils during inflammation.

Most people develop symptomatic emphysema which occurs at an earlier age and with greater severity if individuals smoke.

The following sequence is postulated:1.Neutrophils which is source of elastase

normally sequestered in peripheral capillaries, including those in lung, and few gain access to alveolar space.

2.Any stimulus that increase either the number of leucocytes in the lung wil increase elastase and increase proteolytic activity.

3.With low level of serum alpha-one antitrypsin, elastic tissue destruction is unchecked and emphysema results.

This imbalance also help explains the effect of cigarette smoking in development of emphysema, particularly centriacinar form in subjects with normal amount of alpha-one antitrypsin.

This is because in smokers, neutrophils and macrophages accumulate in alveoli nicotine stimulate reactive oxygen species to attract and activate more neutrophils elastase increasealveoli destruction emphysema

SIGNS AND SYMPTOMS

A person with emphysema will have shortness of breath -- during physical activity and when the condition is more advanced, also during rest.

Patients may eventually need supplemental oxygen and may have to rely on mechanical respiratory devices.

Other symptoms of emphysema include chronic cough, frequent respiratory infections, reduced appetite, weight loss and fatigue.

 

RISK FACTOR

SmokingGenetic deficiency of alpha-one antitrypsinAge

INVESTIGATION

OximetryOxygenated blood is a brighter red and becomes

purpler in color when oxygen is removed. The oximeter is a device usually placed on a finger and detects the pulse of blood. A light is transmitted through the tissue, and the amount of the brighter red color is determined, enabling a measure of oxygen saturation, a measure of hemoglobin oxygen content. This value is usually greater than 90%.

RadiologyA plain chest x-ray may show lungs that have

become too inflated and too lucent, signs that lung tissue destruction has occurred.

Pulmonary Function TestsA variety of lung functions can be measured

and may include how much air the lungs can hold and empty with each breath, the degree of airflow obstruction, the available surface for exchange of carbon dioxide and oxygen, the amount of trapped gases, and how elastic the lungs are with inspiration and expiration.

Blood Tests A complete blood cell count (CBC) may be

performed to check for an increase in the number of red blood cells. In response to lower blood oxygen concentrations, the body manufactures more red blood cells to try to deliver as much oxygen as possible to cells.

An arterial blood gas ( ABGs ) test will measure the amount of oxygen and carbon dioxide in the blood

TREATMENT

BronchodilatorsBronchodilators are used to relax the smooth

muscles that surround the bronchioles and allow the breathing tubes to dilate and allow more air flow. These medications can be inhaled using nebulizer machine These medications can either be short or long acting.

The bronchodilators include the albuterol agents (Ventolin HFA, Proventil HFA, and Pro Air) and the anticholinergic agent, ipratropium bromide (Atrovent).

- Tablets and Extended-Release Tablet : Relief of bronchospasm in adults and children 6 years and older with reversible obstructive airway disease.

ADMINISTRATION

Aerosol and inhalation powder are indicated for children 4 years and older, solution for inhalation for children 2 years and older.

Nebulization ( facemask or mouth piece ). Use compressed air or oxygen with gas flow of 6-10 L/min , single treatment last for 5 to 15 minutes.

Children maintained on the tablets or syrup may be switched to extended-release tablet. ( eg. One 4mg extended-release tablet q 12 hrs is comparable to one 2mg tablet q 6 hrs. )

Take extended-released tablet whole with aid of liquids: do not chew or crush. The outer coating of extended-release tablet will be excreted out in feces.

ACTION KINECTIC

Stimulates beta-2 receptors of bronchi, leading to bronchodilation. Causes less tachycardia and is longer-acting.

DOSAGE

Inhalation aerosolBronchodilationAdults and children over 4 years of age : 180 ( 2 inhalation ) q 4-6 hrs. Maintainence : 180 mcg ( 2 inhalation ) 4

timesper day.Prophylaxis of exercise-induced

bronchospasmAdults and children over 4 years of age:180 mcg ( 2 inhalation ) 15 min before exercise

Inhalation solutionBronchodilationAdult and children over 12 years of age:2.5 mg 3-4 times per day by nebulization

( dilute 0.5 mL of the 0.5% solution with 2.5mL

sterileNNS and deliver over 5-15 min )Children 2-12 years of age :2.5mg 3-4 times per day by nebulization.

SyrupBronchodilationAdults and children over 14 years of age,

usualInitial:- 2-4 mg ( 5-10 mL ) 3-4 times per day, up tomaximum of 8mg 4 times per day.Children over 6-12 years initial:- 0.1 mg/kg 3 times per day, not to exceed

2mg3 times per day

TabletsBronchodilationAdults and children over 12 years of age,

initial:- 2 or 4 mg 3-4 times per day, then increase

dose needed up to maximum of 8 mg 4 times per day, as tolerated.

Children 6-12 years of age, usual, initial :- 2 mg 3-4 times per day, then if necessary

increase the dose in the stepwise fashion to a maximum if 24 mg/day in divided dose.

SIDE EFFECTS

Most common- headache, palpitations/ tachycardia, tremor,

bronchospasm. GIT- diarrhea, dry mouth, appetite loss, epigastric pain CNS- excitement, nervousness, tension, tremor, dizziness,

weakness, drowsiness, restlessness, headache, insomnia, ,malaise, fatique, lightheadedness, aggressive behavior.

Respiratory- Cough, wheezing, dyspnea, bronchospasm, dry throat,

throat irritation, bronchitis CVS- Palpitations, tachycardia, BP changes, hypertension, tight

chest, chest pain.

IPRATROPIUM BROMIDE

USES- Treatment of COPD ( including bronchospasm )

in those who are on regular aerosol bronchodilators theraphy and who inquire a second bronchodilators

Action kinetics :- Ipratropium is an antocholinergic drug that

acts to inhibit the effect of acetylcholine following vagal berve stimulation. This result in bronchodilation which is primarilly a local, site- specific effect.

DOSAGE

AerosolCOPD- 2 inhalations q 6 hours not to exceed 12

inhalations/24 hr Inhalation solutionCOPD- One 3-ml vial given 4 times per day via

nebulization with up to 2 additional 3mL doses daily, if needed.

SIDE EFFECT

Most common:- Bronchitis, URTI, headache, pain, dyspnea,

coughing, nausea, pharyngitis, sinusitis.

AntibioticsSince patients with emphysema are at risk

for infections like pneumonia, antibiotics may be prescribed when the usually clear sputum changes color, or when the patient presents with systemic signs of an infection (fever, chills, weakness).

OxygenAs the disease progresses, patients may

require supplemental oxygen to be able to function. Often it begins with nighttime use, then with exercise, and as the disease worsens, the need to use oxygen during the day for routine activities increases.

COMPLICATION

People with emphysema have a higher mortality than those with normal lung function. Causes of death include respiratory failure, lung infections such as pneumonia and influenza, and other diseases related to smoking. These include cancer, heart disease, and stroke. Eventually, severe shortness of breath will limit the person's normal daily activities.

Emphysema patients are at increased risk of contracting recurrent respiratory infections and lung cancer, and are at high risk for respiratory and coronary failure. Enlargement and strain on the right side of the heart. (Emphysema makes the heart work harder to keep the lungs supplied with blood because of damage to the lungs' circulatory system and other tissue damage.)

NURSING INTERVENTIONS

1. Nursing diagnosis- Difficulty in breathing in related to compressed lung.Objective- Ensure that patient can breath better during the time of admission in ward.Intervention- Position patient in Semi-Fowler’s position so that patient’s lung can expand better as abdominal pressure decrease and patient can breath better and more comfortable.- Assess patients appearance whether there is any blueish as this indicate that patient is not receiving adequate oxygen into the body.- Assess the patients vital sign 4 hourly especially SPO2, breathing pattern, respiratory rate to detect whether patient is receiving enough oxygen into the body.

- Auscultate lungs and document significant change in breath sound to indicate any abnormality in lung such as presence of mucus so that early intervention can be carry out.- Monitor’s ABGs of patient so that PaCO2 and PaO2 in body of patient so that any abnormality is detected.-Give oxygen supply to patient such as nasal prong so that patient can receive more oxygen and cells in body can get enough oxygen.- Give patient bronchodilater so that airway is open and can breath more easily.

2) Nursing diagnosis- Weight loss in related to loss of appetite

Objective- Ensure that patient’s body weight is maintain during times in ward.

Nursing intervention- Assess body weight of patient once a week to indicate any changes in weight so that further interventions can be carry out.

- Give patient’s favourite food so that patient have appetite to eat.

- Encourage patient’s family member to bring food from house so that patient has more appetite to eat.

- Encourage patient to eat more frequent and less amount at the same time.

- Make sure that environment is clean when feeding patient.

- Encourage family member to bring utensils from home so that patient can eat comfortably.

- Encourage patient’s family member to encourage patient to eat more because encourages from family members is most effective.

- Explain the purpose of eating food so that patient can recover faster as food contains protein and vitamins that needed for better recovery.

HEALTH EDUCATION

Encourage patient to reduce smoking so that nicotine will not further damage the alveoli and reduce severity of emphysema.

Encourage patient to perform deep breathing so that lung exercise is perform and lung can recover faster.

Encourage patient’s family member to buy SMI for patient so that patient can perform lung exercise.