Chronic Obstructive Pulmonary Disease
COPD 569
Definition
A disease characterized by airflow limitation that is not fully reversible e.g. emphysema, chronic bronchitis
COPD can coexist with broncial asthma
Incidence
Fifth leading cause of death in men and women of any age.
The disease becomes symptomatic during the middle age.
Increases with age
Pathophysiology
The airflow limitation is progressive
Associated with an abnormal inflmmatory response of the lungs to noxious particles or gases
The inflammation occurs in the airways, parenchyma and pulmonary vasculature - vessel walls thicken.
The inflammation and repair process narrow the small peripheral airways
Scarring and narrowing of the lumen cause obstruction to the airflow
Parenchyma of the lung gets damaged & gas exchange is impaired
Inflammation causes an imbalance of proteinases and antiproteinases in the lung leading to airflow limitation
The parenchymal changes may also be because of inflammation, environmental and genetic factors like alpha1 antitrypsin deficiency
Exposure to cigarette smoke or use of tobacco products may aggravate the disease.
Chronic Bronchitis
A disease of the airways characterized by cough and sputum production for at least 3 months in each of 2 consecutive years.
Smoke or other environmental pollutants irritate the airways → Hypersecretion of mucus and inflammation - ciliary function of the epithelium is reduced
Bronchial wall is thickened
Bronchial lumen is narrowed
Mucus plugs obstruct airflow
Alveoli damaged and fibrosed
Function of the alveolar macrophages altered → foreign particles and bacteria are not destroyed → respiratory infection viral, bacterial and mycoplasmal - bronchitis
Chronic Bronchitis exacerbate during winter.
Emphysema
In emphysema gas exchange is impaired (O2 and CO2)
Destruction of the wall and overdistension of the alveoli occurs
It is the end stage of a process that has progressed for many years
Alveolar surface in contact with pulmonary capillaries decreases → increase in dead space
Impaired O2 diffusion leads to hypoxemia.
CO2 elimination decreases → pCO2 increases (partial pressure of CO2 in blood) - hypercapnia → respiratory acidosis
Pulmonary blood flow increases
Right ventricle works harder
Pulmonary blood pressure increases
Right sided heart failure may develop (Cor Pulmonale - congestion, dependent edema, distended neck veins, pain in the region of liver)
Two types of emphysema :
Panlobular emphysema - Panlobular (panacinar) - destruction of the respiratory bronchiole, alveolar duct and alveoli. all air spaces are enlarged but no inflammatory disease. (Barrel chest) - expiration instead of being passive becomes an active process - chest rigid - ribs fixed at the joints.
Centrilobular - (centroacinar) - pathological changes in the center of the secondary lobule - derangement of ventilation-perfusion ratios - chronic hypoxemia and hypercapnia occur - polycythemia + → central cyanosis, peripheral edema, and respiratory failure
Both the types can occur in the same patient
Risk Factors
(Causes)
Cigarette smoking
Pipe, cigar and other types of tobacco smoking
Passive smoking
Smoking depresses the activity of scavenger cells and ciliary cleansing mechanism
Carboxyhemoglobin is produced
Exposure to occupational dusts and chemicals, indoor air pollution, outdoor air pollution
A deficiency of Alpha1 antitrypsin deficiency - genetic - genetic counseling - Alpha-protease inhibitor replacement therapy.
Clinical Manifestations
Cough
Sputum production
Dyspnea on exertion
Weight loss
Dyspnea even at rest later
Accessory muscle in action → risk of acute and chronic respiratory failure
Barrel chest
Shoulders heave upward
Abdominal muscles may also contract on inspiration
Assessment and Diagnostic Findings
Spirometry Ratio of FEV1 (volume of air that the patient can forcibly exhale in 1 second) to Forced vital capacity FVC
FEV1/FVC ratio is less than 70%
Bronchodilator reversibility testing : test with spirometry before and after bronchodilator
ABG (arterial blood gas)
Chest X-ray chest to rule out other causes of dyspnea
Alpha1 antitrypsin deficiency screening for those below 45
Differential Diagnosis
Asthma onset early in life, variation in daily symptoms, in day to dya occurrence, reversible
Complications
Respiratory insufficency
Respiratory failure
Pneumonia
Atelectasis
Pneumothorax
Cor pulmonale
Pharmacological Therapy
Nursing Management
Nursing Process
Assessment
Elicit current symptoms
Elicit previous symptoms
Take a complete history
Nursing Diagnosis
Impaired gas exchange and airway clearance due to chronic inhalation of toxins
impaired gas exchange related ventilation-perfusion inequality
How is airway clearance
How effectivw is breathing pattern
Mucus + or -
Whether cough is effective
Any airway irritants
Extent of activity intolerance
Knowledge
Presence of anxiety, less socialization, depression, inability to work
Collaborative problems / Potential complications
Respiratory insufficiency or failure
Atelectasis
Pulmonary infection
Pneumonia
Pneumothorax
Pulmonary hypertension
Planning and Goals
Stop smoking
Improved gas exchange
Airway clearance
Improved breathing pattern
Increased activity tolerance
Self management
Follow therapeutic program
Home care
Absence of complications
Nursing Interventions
Promote cessation of smoking
Relieve the bronchospasm and inprove gas exchange
Achieve airway clearance - diminish viscosity and quantity of sputum - eliminate irritants - teach coughing - "huff" coughing
Chest physiotherapy with postural drainage
Intermittent positive pressure breathing
Increase fluid intake
Bland aerosol mist
Improve breathing pattern
Univesity Question
Mr. Ranganath a chronic smoker aged 65 years admitted with breathlessness is diagnosed as a case of COPD. Define COPD and list the causes of COPD.
Discuss the findings on respiratory assessment. Explain the nursing care of this patient using nursing process approach
