Tracy Petleski, MSN, RN

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Tracy Petleski, MSN, RN

• Altered Respiratory Function
• Unit VI

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Chronic Obstructive Pulmonary Disease- COPD

• Characterized by restrictive air-flow issues that
  are irreversible
• Air flow obstruction
• Co-exist w/ other respiratory disorders
• COPD is not reversible

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COPD
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5th leading cause of death in the U.S.

• 5th for men
• 4th for women
• 16 million Americans have a form of COPD
• Over 13 million visits to the MD annually
• 1/3 of patient receiving homecare secondary to
  COPD

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COPD

• Airflow limitations as well as abnormal
  inflammatory response of the lungs to noxious
  stimuli
• Body tries to correct chronic inflammation
  causing scarring and narrowing of airway lumen.
  paraenchymal is destroyed and emphysema disease
  of alveoli and or gas exchange disruption (COPD)

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COPD Risk factors

• Smoking
• Environmental exposure
• Cigars and pipes tobacco
• Prolonged intense occupational exposure
• Dusts, chemicals, indoor pollution as well as
  outdoor pollution

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COPD- other risk factors

• Genetics
• Alpha deficiency, antitrypsin (protects
  paraenchyma)
• 1 cause of killer among young Americans in the
  absence of smoking
• Sensitive to environmental factors

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COPD

• Symptoms
• Cough, sputum production and exertional dyspnea
• Weight loss
• Accessory muscle
• Barrel chest

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Diagnosis

• ABGs
• CXR
• Alpha1 antitrypsin deficiency screening
• Familiar history
• Severity stages
• I-IV

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COPD

• Diagnosis
• Spirometry. Amount of air the patient can
  forcibly exhaled. (1 second). To forced vital
  capacity. Expressed in absolute volume as a
  percentile
• Difficult exhaling or cannot forcibly exhale.
  Obstructive disease is defined as FEV1/FVC ratio
  less than 70
• Reversibility is demonstrated if pulmonary
  function test improves after bronchodilators

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COPD- medical management

• Smoking cessation
• Bronchodilators
• Corticosteroids
• Oxygen therapy

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COPD

• Medications to reduce bronchospasm and reduce
  constricted airways (beta 2antagonist)
• Metaproterenol (Alupent)
• Albuterol (Proventil)
• Xanthines (Theophyllines)
• Others
• Corticosteroids
• Anticholinergics (Atropine, Atrovent)
• Leukotrines inhibitors

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COPD -complications

• Life- threatening
• Respiratory insufficiency and failure

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Chronic bronchitis

• Disease of the airways
• Cough and sputum x 3 months over 2 years
• Airway irritants results in hyper-secretion
  mucous production and inflammation
• Bronchiole wall becomes thickened
• Bronchiole lumen is narrowed
• Mucous plugs the airway

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Chronic bronchitis

• Refers to inflammatory changes and excessive
  mucous production in the bronchial tree
• Characterized by hyperplasia and hypertrophy of
  mucous producing glands
• Results from prolonged exposure to irritants

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Chronic bronchitis

• Patients susceptible chronic infections
• Winter

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Chronic bronchitis- diagnosis

• Clinically diagnosed by the presence of a cough
  with sputum occurring on most days for at least 3
  months in a year for at least 2 consecutive years
• Alveoli are not seriously affected

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Emphysema

• Impaired gas exchange
• Over distended alveoli
• (abnormal distension of the air spaces beyond the
  terminal bronchioles w/ destruction of the walls
  of the alveoli
• End stage of disease that progresses over many
  years
• As alveoli is destroyed by recurrent infection
• Alveolar surface is decreased

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Emphysema

• Pulmonary capillaries decrease increasing the
  dead space
• Impaired diffusion which leads to hypoxia
• Later CO2 elimination is impaired (hypercapnia)
• Respiratory acidosis
• Capillary beds are decreased, increasing blood
  flow via R ventricle to maintain higher blood
  pressure in pulmonary artery. R CHF is
  complication of emphysema (congestion, dependent
  edema,neck vein distension, liver pain and CV
  failure).

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Emphysema

• Results in
• Reduced alevolar function surface area and the
  number of pulmonary capillaries
• Decrease in the area for gas exchange
• Increase resistance to pulmonary blood flow
• Expiration becomes a muscular act
• Over time the chest becomes rigid (barrel-
  shaped)
• Use accessory muscles of the neck, chest and
  abdomen to breath

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Bronchiectasis

• Not considered COPD. Separate disease process
• Airway obstruction
• Diffuse airway disease
• Cystic fibrosis
• Abnormal host
• Ideopathic causes (recurrent respiratory
  infections)
• Measles, influenza, TB and immunodeficiency

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Bronchiectasis

• Inflammatory process, seconadry to infections
  that damage bronchial walls
• Loss of supporting structure, causing thick
  sputum
• Leading to obstruction of of bronchi
• The walls become permanently distended and
  distorted

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Bronchiectasis

• Localized and affecting lower lobes in the lung
• Retention of secretions and subsequent
  obstruction and alveoli collaspe
• Airway pooling of thick copious thick purulent
  secretions
• May be congenital or due to complication of
  infection or aspiration
• May need postural drainage and surgery

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Bronchioectasis- assessment

• Acute event of worsening dyspnea (even at rest)
• Increased sputum production
• Increased malaise
• Nocturnal awakening with dyspnea and wheezing
• Frequent headaches

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Bronchioectasis -assessment

• Patient is likely to present with respiratory
  distress
• Often sitting upright, leaning forward to
  facilitate breathing
• Using pursed lip breathing
• Using accessory muscles

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Bronchiectasis

• Diagnosis
• Difficult. Specific history of productive cough
  w/ tuberculi negative sputum
• CT chest bronchiole dilation

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Bronchioectasis

• Medical management
• Promote bronchiole drainage
• Prevention of infection
• Smoking cessation
• Pneumonia vaccines
• bronchodilators

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Bronhioectasis- nursing interventions

• Medical history
• Establish IV access
• Telemetry
• If patient has a productive cough encourage
  coughing
• Collect sputum specimen
• Administer oxygen
• Assist with ventilation

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Asthma

• Chronic diffuse inflammatory disease,
  hyperresponsiveness, mucosal edema reducing
  airway diameter causing narrowing and increased
  mucous production, blocking bronchi
• Differs from other obstructive disease reversible
  
• 17 million Americans
• Over 14 million physician visits
• 2 million visits to ED

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Asthma

• Occurs in acute episodes of variable duration
• Characterized by reversible airflow obstruction
• Bronchial smooth muscle and hypersecretion of
  mucous resulting bronchiole plugging
• Inflammatory response in bronchial walls

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Asthma

• Alveolar hypoventilation
• Hypoxemia
• Hyperventilation (carbon dioxide retention)
• Increased airway resistance- air trapping
• Excessive demand on respiratory muscles
• Accessory muscle use
• Increased respiratory fatigue

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Asthma

• Symptoms
• Cough, congestion, chest tightness, wheezing and
  dyspnea
• Night time
• Symptoms may be latent or acute periods of
  exacerbations (minutes-days- weeks)
• Any age
• Childhood
• Disruptive disease
• Allergies are strongest predisposing factor

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Asthma

• Symptoms
• Symptoms worsen over time
• Expiration is prolonged
• Hypoxia (ventilation-perfusion mismatch)
• Central cyanosis

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Asthma- assessment

• Prolonged expiratory phase with wheezing
• Inspiratory wheezing suggests secrections in
  large airways
• A silent chest may indicate severe obstruction
  and flow rates that are low

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Asthma- assessment

• Obtunded
• Diaphoresis and pallor
• Retractions
• Inability to speak
• Poor muscle tone, floppy
• Rapid heart rate 130/min
• Rapid respirations 30 breaths/min
• Agitation or mentally foggy

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Asthma

• Diagnosis
• Family, environmental and occupational history
• Symptomology
• GERD
• Medication induced
• Allergies

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Asthma

• Complications
• Status asthmaticus
• Respiratory failure
• Pneumonia
• Atelectasis
• Hypoxia
• Death

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Asthma- management

• Maintain airway
• Supplemental oxygen
• Reverse bronchospasm
• IV hydration
• Position of comfort to maximize respiration

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Asthma- medications

• Corticosteroids long acting
• Long acting beta2-adrenergic agonists
• Bronchodilators theophylline, slo-bid
• Leukotrienes
• Short acting Atrovent
• Combination therapy
• Albuterol/ ipratropium Combivent

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Asthma- nursing

• Anxiety
• Pulse oximetry
• Dyspnea
• Vital signs
• Dehydration
• Medications
• Intubation

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COPD- medications
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Vaccines

• Pneumonvax
• Pneumococcal immunization
• Eggs are not used in the production of this
  vaccine
• Anaphylaxis
• Do not give more less than 3 years apart
• Avoid w/ DPT allergy
• Afebrile
• Education
• Localized reaction, fever, N,V and D.

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Vaccines

• Influenza
• Influenza, promotes antibodies production.
• Egg allergy should AVOID vaccine
• Avoid acute respiratory infection and
  neurological disorders
• Timing is essential
• Dont give w/ pertussis (3 days) or w/ DPT

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Vaccines

• Influenza
• Is safe in pregnant women
• Older than 6 months
• Occupational recommended
• Special populations considerations?

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Vaccine

• Influenza
• Education
• Vaccine does not cause flu
• Treat aches, fever and malaise w/ OTC
• Safe
• Strongly recommended for anyone older than 6
  months