Chronic Obstructive Pulmonary Disease (COPD)

COPD Depression and Anxiety

- COPD patients experience many losses - If patient becomes anxious because of dyspnea, teach pursed lip breathing The nurse should ask the patient if he or she "feels down or blue" most of the time. Do patients appear anxious about being able to control their symptoms of breathlessness or know what to do if they have an exacerbation? Are they exhibiting concern over more difficulty in self-care activities such as bathing? How is the family coping with the patient's disease? Cognitive and behavioral therapy along with COPD teaching may improve the quality of life. Medications may be used to treat both the depression and anxiety. Buspirone (BuSpar), which is used to treat anxiety, has few if any respiratory depression effects.

COPD Gender

- In the past, COPD prevalence and mortality were greater in men than women - Now the prevalence is almost equal In the past, COPD prevalence and mortality were greater in men than women. Now the prevalence is almost equal, reflecting the changing patterns of cigarette smoking. Women may be more susceptible to the adverse effects of smoking.

Nursing Management Nursing Diagnoses

- Ineffective breathing pattern - Ineffective airway clearance - Impaired gas exchange - Imbalanced nutrition: - Less than body requirements - Risk for infection

COPD Infection

- Recurring infections impair normal defense mechanisms - HIV - Tuberculosis Severe recurring respiratory tract infections in childhood have been associated with reduced lung function and increased respiratory symptoms in adulthood, while it is unclear if recurrent infections in adults are related to development of COPD. People who smoke and also have HIV infection have an accelerated development of COPD. Tuberculosis is also a risk factor for COPD development.

COPD End-of-Life Considerations

- Symptoms can be managed, but COPD cannot be cured - End-of-life issues and advanced directives are important topics for discussion - Palliative care, end-of-life and hospice care are important in advanced COPD

COPD Asthma

1. Considerable pathologic and functional overlap between asthma and COPD 2. Older adults may have components of both diseases - Asthma-COPD overlap syndrome Patients with COPD may have asthma. Asthma may be a risk factor for the development of COPD.

Nursing Management Nursing Assessment

1. Obtain complete health history and conduct a complete physical assessment

COPD Gerontologic Considerations

1. Reduced lean body mass and decreased respiratory muscle strength may increase dyspnea and lower exercise tolerance 2. This causes - Poorer ADL status - Higher incidence of acute exacerbations 3. COPD complicated by co-morbidities - Cardiovascular disease - Serious infections - Osteoporosis - Psychologic problems - Impaired cognition - Lung cancer The presence of co-morbidities can make it difficult for patients to cope with the stress of an exacerbation. Thus assessment of comorbidities can assist in ensuring comprehensive and safe management, especially during an exacerbation. Older patients may have difficulty in handling the increased secretions during an acute COPD exacerbation. The use of additional medications to manage the acute exacerbation can complicate disease management and increase the likelihood of adverse events. Some medication used to treat common disorders in older adults, such as hypertension, can worsen COPD symptoms.

COPD Heredity

1. alpha-Antitrypsin (AAT) deficiency - Genetic risk factor for COPD - Accounts for 3% of COPD - AAT is an autosomal recessive disorder. AAT, a α1-protease inhibitor, is a serum protein produced by the liver and normally found in the lungs. Its main function is to protect normal lung tissue from attack by proteases during inflammation related to cigarette smoking and infections. Severe AAT deficiency leads to premature bullous emphysema in the lungs found on x-ray. Emphysema occurs because of AAT deficiency. Lower levels of AAT result in insufficient inactivation and subsequent destruction of lung tissue. The most common abnormal genes are the S and Z alleles; normal genes are labeled M. The most common genotype associated with AAT disease is ZZ. A simple blood test can determine low levels of AAT. Those with borderline or low levels can then be genetically tested. IV-administered AAT (e.g., Prolastin-C) augmentation therapy is used for persons with AAT deficiency.

COPD Description

Airflow limitation not fully reversible - Usually progressive - Abnormal inflammatory response of lungs, primarily caused by cigarette smoking and other noxious particles or gases - Definitions previously included chronic bronchitis and emphysema - Chronic bronchitis is an independent disease - Emphysema is a pathologic term that explains only one of several structural abnormalities in COPD COPD exacerbations and other coexisting illnesses or co-morbidities contribute to the overall severity of the disease. Chronic bronchitis, the presence of cough and sputum production for at least 3 months in each of 2 consecutive years, is an independent disease that may precede or follow the development of airflow limitation. Emphysema is the destruction of the alveoli, and is a pathologic term that explains only one of several structural abnormalities in COPD patients. COPD Etiology Risk factors - Cigarette smoking - Occupational chemicals and dust - Air pollution - Severe recurring respiratory infections α1-antitrypsin deficiency α1-antitrypsin deficiency (an autosomal recessive disorder) is a risk factor for developing COPD. Some degree of emphysema has been thought to occur as a person ages. It is caused by changes in the lung structure and the respiratory muscles, even in a nonsmoker.

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

Answer: A Rationale: In later stage COPD, the patient will have a low or low normal pH, a high normal or above normal PaCO2, and a high normal or above normal HCO3-. This indicates compensated respiratory acidosis, as the patient has chronically retained CO2 and the kidneys have conserved HCO3- to increase the pH to near or within the normal range.

COPD Occupational & Environmental

COPD can develop with intense or prolonged exposure to - Dusts, vapors, irritants, or fumes - High levels of air pollution - Fumes from indoor heating or cooking with fossil fuels The effect of outdoor air pollution as a risk factor for the development of COPD is unclear. Use of coal and other biomass fuels for indoor heating and cooking are also a risk factor. Many women, particularly worldwide, who have never smoked are developing COPD because of cooking with these fuels in poorly ventilated areas. If a person has occupational exposure and smokes, the risk of COPD increases.

Nursing Management Evaluation

Expected Outcomes - Return to baseline respiratory function - Demonstrate an effective rate, rhythm, and depth of respirations - Experience clear breath sounds - Maintain clear airway by effective coughing - PaCO2 and PaO2 return to levels normal for patient - Maintenance of normal body weight - Normal serum protein levels - Feeling of being rested - Improvement in sleep pattern - Awareness of need to seek medical attention - Behaviors minimizing risk of infection No infection

Nursing Management Planning

Goals - Prevention of disease progression - Ability to perform ADLs - Relief from symptoms - No complications related to COPD - Knowledge and ability to implement long-term regimen - Overall improved quality of life

Nursing Management Nursing Implementation

Health Promotion - Abstain from or stop smoking. - Avoid or control exposure to occupational and environmental pollutants and irritants. - Early detection of small-airway disease - Early diagnosis and treatment of respiratory tract infection - Awareness of family history of COPD and AAT deficiency 1. Acute Care - Required for acute exacerbations, pneumonia, cor pulmonale, or acute respiratory failure - Degree and severity of underlying respiratory problem should be assessed 2. Ambulatory Care A. Most important aspect is teaching - Pulmonary rehabilitation - Activity considerations - Sexual activity - Sleep - Psychosocial considerations 3. Pulmonary rehabilitation (PR) is designed to reduce symptoms and improve quality of life 4. Includes exercise training, smoking cessation, nutrition counselling, and education 5. Activity considerations - Exercise training leads to energy conservation - In upper extremities, it may improve muscle function and reduce dyspnea 6. Activity considerations A. Modify ADLs to conserve energy - Hair care, shaving, showering - O2 during activities of hygiene B. Walk 15 to 20 minutes a day at least 3 times a week with gradual increases - Adequate rest should be allowed C. Exercise-induced dyspnea should return to baseline within 5 minutes after exercise 7. Psychosocial considerations - Healthy coping is a challenge - May feel guilt, depression, anxiety, loneliness from social isolation, denial, and frustration from increased dependence 8. Sexual activity - Plan when breathing is best - Use slow, pursed lip breathing - Refrain after eating or drinking alcohol - Choose less stressful positions - Use O2 if prescribed 9. Sleep A. Adequate sleep is extremely important B. Can be difficult because of medications, postnasal drip, or coughing - Nasal saline sprays, decongestants, or nasal steroid inhalers can help As health care professionals, nurses who smoke should reevaluate their own smoking behavior and its relationship to their health. Nurses and other health care providers who smoke should be aware that the odor of smoke is obvious on their clothes, and it can be offensive or tempting to patients. People who have COPD should avoid others who are sick, practice good hand-washing techniques, take medications as prescribed, exercise regularly, and maintain a healthy weight. Influenza and pneumococcal pneumonia vaccines are recommended for patients with COPD. Genetic counseling is appropriate for the patient with AAT deficiency who is planning to have children. Pulmonary rehabilitation can be done in an inpatient or outpatient setting, or in home settings. Works best if the patient starts it when COPD is in the moderate stage. A mandatory component of any pulmonary rehabilitation program is exercise that focuses on the muscles used in ambulation. In PR an interprofessional team works together to individualize the treatment plan for COPD patients. Physical therapists or nurses who have experience in pulmonary care are often responsible for the management of pulmonary rehabilitation centers. A large part of your role is to teach patients self-management of their disease. Frequently the patient has already adapted alternative energy-saving practices for ADLs. Alternative methods of hair care, shaving, showering, and reaching may need to be explored. An occupational therapist may help with ideas in these areas. Alternative methods of hair care, shaving, showering, and reaching may need to be explored. If the patient uses home O2 therapy, O2 should be used during activities of hygiene because these are energy consuming. Walking or other endurance exercises (e.g., cycling) combined with strength training are likely the best intervention to strengthen muscles and improve the patient's endurance. Some patients benefit from using their β2-adrenergic agonist approximately 10 minutes before exercise. The nurse should instruct the patient to wait 5 minutes after completion of exercise before using the β2-adrenergic agonist to allow a chance to recover. During this time, slow, pursed lip breathing should be used. People with COPD frequently have to deal with many lifestyle changes that may involve decreased ability to care for themselves, decreased energy for social activities, and loss of a job. It is important to convey a sense of understanding and caring to the patient. The patient with COPD may benefit from stress management techniques (e.g., massage, muscle relaxation). Teach patients about the treatment and disease, which can give them a sense of control of their disease and complex treatment regimens, and include the patient's caregiver in the teaching. Support groups at local American Lung Association chapters (such as the Better Breathers Club), hospitals, and clinics can also be helpful. The nurse will need to first assess the patient related to sexuality and concerns of functioning. Ask open-ended questions to determine if the patient wants to discuss any of these concerns, such as "How has your breathing problem affected how you see yourself as a woman or man?" or "How does your shortness of breath affect your desire for intimacy with your partner?" Erectile dysfunction can occur with COPD as with many chronic diseases. Using an inhaled bronchodilator before sexual activity can help ventilation. The hyperinflation of the lungs and the reduction in ventilation can result in severe drops in O2 saturation (down to 60% or less) during sleep. This leads to a strain on the heart. In addition, hypercapnia may develop with more frequent awakening. The net result is poor quality of sleep and awakening unrefreshed and fatigued. If the patient is prescribed O2 therapy, it should be used as it will help decrease insomnia.

COPD Pathophysiology

In COPD various disease processes occur such as airflow limitation, air trapping, gas exchange abnormalities, mucous hypersecretion, and, in severe disease, pulmonary hypertension with systemic features. Gas exchange abnormalities result in hypoxemia and hypercarbia (increased CO2) as the disease worsens. As the air trapping worsens and alveoli are destroyed, bullae (large air spaces in the parenchyma) and blebs (air spaces adjacent to pleurae) can form. Bullae and blebs are not effective in gas exchange, since they do not contain the capillary bed that normally surrounds each alveolus. Therefore a significant ventilation-perfusion (V/Q) mismatch and hypoxemia result. COPD Clinical Manifestations 1. Develops slowly 2. Diagnosis is considered with - Chronic cough or sputum production - Dyspnea - Exposure to risk factors 3. Dyspnea usually prompts medical attention - Occurs with exertion in early stages - Present at rest with advanced disease 4. Causes chest breathing - Use of accessory and intercostal muscles - Inefficient breathing 5. May experience wheezing and chest tightness 6. Characteristically underweight with anorexia 7. Chronic fatigue 8. Paroxysmal coughing may be so severe that patient faints or fractures ribs 9. Physical examination findings - Prolonged expiratory phase - Wheezes - Decreased breath sounds - ↑ Anterior-posterior diameter (barrel chest) - Tripod position - Pursed lip breathing 10. Polycythemia and cyanosis - Hypoxemia - Increased production of red blood cells - Bluish-red color of skin - Hemoglobin concentrations may reach 20 g/dL (200 g/L) or more Clinical manifestations of COPD typically develop slowly and should be considered in patients over 40 years of age, and after 20 pack-years of cigarette smoking. A chronic intermittent cough usually occurs in the morning and may or may not be productive of small amounts of sticky mucus. These symptoms can occur many years before actual airflow limitation. Dyspnea typically is progressive, usually occurs with exertion, and is present every day. Patients usually ignore the symptoms and rationalize that, "I'm getting older" and "I'm out of shape." They change behaviors to avoid dyspnea, such as by taking the elevator. Gradually, the dyspnea interferes with daily activities, such as carrying grocery bags, and they cannot walk as fast as their spouse or peers. In late stages of COPD, dyspnea may be present at rest. As more alveoli become overdistended, increasing amounts of air are trapped. This causes a flattened diaphragm, and the patient must breathe from partially inflated lungs. Effective abdominal breathing is decreased because of the flattened diaphragm from the overinflated lungs. The person becomes more of a chest breather, relying on the intercostal and accessory muscles. However, chest breathing is not efficient. Wheezing and chest tightness may be present but may vary by time of day or from day to day, especially in patients with more severe disease. Wheezes may arise from the laryngeal area, or wheezes may not be present on auscultation. Chest tightness, which often follows activity, may feel similar to muscular contraction. Even when the patient has adequate caloric intake, weight loss is experienced. Fatigue is a highly prevalent symptom that affects the patient's activities of daily living. The patient may need to breathe louder than normal for auscultated breath sounds to be heard. The patient may sit upright with arms supported on a fixed surface such as an overbed table (tripod position). The patient may naturally purse lips on expiration (pursed lip breathing) and may use accessory muscles, such as those in the neck, to aid with inspiration. Over time, hypoxemia (PaO2 <60 mm Hg or O2 saturation <88%) may develop with hypercapnia (PaCO2 >45 mm Hg). Polycythemia develops as a result of increased production of red blood cells as the body attempts to compensate for chronic hypoxemia. Hemoglobin concentrations may reach 20 g/dL (200 g/L) or more. However, the person may also have lowered hemoglobin and hematocrit because of chronic anemia. Edema in the ankles may be the only clue to right-sided heart involvement (cor pulmonate). COPD Diagnostic Studies 1. History and physical exam 2. Diagnosis confirmed by spirometry - FEV1/FVC ratio <70% - Increased residual volume - Chest x-ray - 6-minute walk test - COPD Assessment Test (CAT) - Clinical COPD Questionnaire (CCQ) - ABGs - Echocardiogram or multigated acquisition (MUGA) (cardiac blood pool) scan - Sputum for culture and sensitivity 3. ABG typical findings in later stages - Low PaO2 - ↑ PaCO2 - ↓ pH - ↑ Bicarbonate level found in late stages of COPD Spirometry confirms the presence of airflow obstruction and determines the severity of COPD. The patient is given a short-acting bronchodilator, and post-bronchodilator values are compared to a normal reference value. A diagnosis of COPD is made when the forced expiratory volume in one minute/forced vital capacity (FEV1FVC) ratio is less than 70% along with the appropriate symptoms. The value of FEV1 provides a guideline for the degree of severity of COPD. FEV1 can be expressed as a percentage compared with a normal reference value (% predicted). The lower the FEV1 the sicker the patient. Chest x-rays are not diagnostic but may show a flat diaphragm due to the hyperinflated lungs. Patients often have exercise-induced hypoxemia, and thus a 6-minute walk test should be done by physical or respiratory therapy, with pulse oximetry readings taken when the patient is walking and at rest. If values of oxygen saturation are 88% or lower when at rest and the patient is breathing room air, they qualify for supplemental oxygen. The CAT provides a measure of the daily impact of COPD on a person's life and can help the health care team make better management decisions. ABGs are usually assessed in the severe stages (FEV1 less than 50%) and monitored in patients hospitalized with acute exacerbations. In the later stages of COPD, typical findings are low PaO2, elevated PaCO2, decreased or low-normal pH, and increased HCO3− levels. An echocardiogram or multigated acquisition (MUGA) (cardiac blood pool) scan can be used to evaluate right- and left-sided ventricular function. Sputum for culture and sensitivity may be obtained if the patient is hospitalized for an acute exacerbation and has not responded to antibiotic therapy. ABGs are usually assessed in the severe stages (FEV1 less than 50%) and monitored in patients hospitalized with acute exacerbations. In early stages, there may be a normal or only slightly decreased PaO2 and a normal PaCO2 COPD Classification 1. Classified as - Mild - Moderate - Severe - Very severe An FEV1/FVC ratio of less than 70% establishes the diagnosis of COPD, and the severity of obstruction (as indicated by FEV1) determines the stage of COPD. The management of COPD is based on the patient's symptoms, classification, and exacerbation history. COPD Complications - Cor pulmonale - Exacerbations of COPD - Acute respiratory failure - Peptic ulcer disease - Depression/anxiety COPD Inter professional Care 1. Stable COPD - Treated as outpatients - Hospitalized for complications: - Acute exacerbations - Acute respiratory failure 2. Evaluate for environmental or occupational irritants 3. Influenza virus vaccine 4. Pneumococcal vaccine 5. Smoking cessation - Biggest impact in reducing risk of developing COPD - Accelerated decline in pulmonary function slows to almost nonsmoking levels 6. Drug therapy A. Bronchodilators - Relax smooth muscle in the airway - Improve ventilation of the lungs - ↓ Dyspnea and ↑ FEV1 - Inhaled route is preferred. B. Commonly used bronchodilators - β2-Adrenergic agonists - Anticholinergics - Methylxanthines C. In COPD patients with FEV1 < 60% - Inhaled long-acting anticholinergic (LABA) - Inhaled corticosteroids (ICS) D. In patients with severe COPD and chronic bronchitis - rofumilast (Daliresp) E. Antibiotic therapy - Azithromycin (Zithromax) F. Phosphodiesterase inhibitor - Roflumilast (Daliresp) G. Combivent Respimat (ipratropium and albuterol) 7. O2 therapy is used to - Keep O2 saturation > 90% during rest, sleep, and exertion, or - PaO2 > 60 mm Hg Long-term O2 therapy improves - Survival - Exercise capacity - Cognitive performance - Sleep in hypoxemic patients O2 delivery systems are 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) 8. Humidification - Used because O2 has a drying effect on the mucosa - Supplied by nebulizers, vapotherm, and bubble-through humidifiers 9. Complications of oxygen therapy - Combustion - CO2 narcosis - O2 toxicity - Absorption atelectasis - Infection 10. Long-term O2 therapy (LTOT) at home improves - Prognosis - Mental status - Exercise intolerance 11. Chronic O2 therapy at home reduces - Hematocrit - Pulmonary hypertension - Periodic reevaluations are necessary to determine duration of use 12. Respiratory and physical therapy A. Breathing retraining B. Effective coughing C. Chest physiotherapy - Percussion - Vibration - Postural drainage 13. Respiratory and physical therapy A. Airway clearance devices B. High-frequency chest wall oscillation - The Vest 14. Breathing retraining A. Decreases dyspnea, improves oxygenation, and slows respiratory rate - Pursed lip breathing (PLB) - Diaphragmatic (abdominal) breathing 15. Pursed lip breathing - Prolongs exhalation and prevents bronchiolar collapse and air trapping - Teach patients to use "just enough" positive pressure Diaphragmatic (abdominal) breathing A. Focuses on use of diaphragm to - Achieve maximum inhalation - Slow the respiratory rate B. May increase the workload of breathing 16. Effective coughing A. Main goals - Conserve energy - Reduce fatigue - Facilitate removal of secretions B. Huff coughing 17. Chest physiotherapy indicated for - Excessive, difficult-to-clear bronchial secretions - Retained secretions in artificial airway - Lobular atelectasis from mucous plug 18. Postural drainage - Gravity assists in bronchial drainage - Techniques are individualized according to patient's pulmonary condition and response to initial treatment - Commonly ordered 2 to 4 times per day 19. Percussion - Hands in a cuplike position to create an air pocket - Air-cushion impact facilitates movement of thick mucus - If it is performed correctly, a hollow sound should be heard 20. No percussion over - Kidneys - Sternum - Spinal cord - Bony prominences - Tender or painful area 21. Vibration - Facilitates movement of secretions to larger airways - Mild vibration tolerated better than percussion 22. Flutter mucus clearance device - Provides positive expiratory pressure (PEP) treatment - Produces vibration in lungs to loosen mucus for expectoration - Handheld device 23. Acapella - Vibrates lungs to shake free mucous plugs - Improves clearance of secretions - Faster and more tolerable than CPT 24. TheraPEP Therapy System - Provides sustained PEP while simultaneously delivering aerosols - The pressure indicator provides visual feedback 25. High-frequency chest wall oscillation - Inflatable vest that vibrates the chest - Works on all lobes - More effective than CPT 26. Nutritional therapy A. Malnutrition in COPD patients is multifactorial - Increased inflammatory mediators - Increased metabolic rate - Lack of appetite B. To decrease dyspnea and conserve energy - Rest at least 30 minutes before eating - Avoid exercise for 1 hour before and after eating - Use bronchodilator - Supplemental O2 may be helpful - High-calorie, high-protein diet is recommended - Eat five to six small meals to avoid bloating and early satiety C. Avoid - Foods that require a great deal of chewing - Exercises and treatments 1 hour before and after eating - Gas-forming foods 27. Surgical therapy A. Lung volume reduction surgery (LVRS) - Remove diseased lung to enhance performance of remaining healthy lung tissue - Results in decreased airway obstruction and increased room for remaining normal alveoli to expand B. Bronchoscopic lung volume reduction surgery - One-way valves are placed in the airways leading to the diseased parts of the lung. - Collapses a certain segment of the lung - Similar result as LVRS C. Bullectomy - Bullae are large air sacs that form from destroyed alveoli - One or more large bullae are removed to improve lung function D. Lung transplantation - Single lung—Most common because of donor shortages - Prolongs life - Improves functional capacity - Enhances quality of life For example, the nurse should teach the patient to avoid aerosol hair sprays and smoke-filled rooms. The patient with COPD and/or smokers should have a vaccination with influenza virus vaccine yearly. The pneumococcal vaccine is recommended for all smokers age 19 or older and all patients with COPD. Medications are given in a stepwise fashion according to the level of airflow obstruction determined from spirometry (FEV1) and symptoms. Medications are stepped up but usually not stepping down as in asthma, because in COPD, continual symptoms are probably present. The choice of bronchodilator depends on the patient's response. However, when the patient has mild COPD or fewer symptoms, a short-acting bronchodilator is used as needed. Albuterol or ipratropium may be used as single agents, but combining bronchodilators improves their effect and decreases the risk of adverse effects. These two agents (albuterol and ipratropium) can be nebulized together (DuoNeb) or delivered by one MDI (Combivent Respimat). In the moderate stage of COPD, a long-acting bronchodilator may be used in addition to a short-acting rescue bronchodilator, such as salmeterol or formoterol. The use of long-acting theophylline in the treatment of COPD is controversial because it interacts with many drugs. A low dose of theophylline with an ICS may benefit a few patients with COPD who do not respond to other inhaled medications The addition of inhaled corticosteroid (ICS) to long-acting bronchodilator therapy is often prescribed in COPD patients with FEV1<60%. ICS combined with long-acting β2-adrenergic agonists (e.g., fluticasone/salmeterol [Advair]) are more effective than single-drug therapy in reducing exacerbations and improving lung function. Some patients are on triple therapy with salmeterol/fluticasone (Advair) and tiotropium (Spiriva). Roflumilast (Daliresp) is an oral medication used to decrease the frequency of exacerbations in patients with severe COPD and the presence of chronic bronchitis. This drug is a phosphodiesterase inhibitor, which is an antiinflammatory drug that suppresses the release of cytokines and other inflammatory mediators, and inhibits the production of reactive oxygen radicals. The antibiotic azithromycin (Zithromax) may be used daily in some COPD patients to prevent recurrent COPD exacerbations. Its effect is due to the antiinflammatory and immune effect, not the antibacterial effect. Roflumilast (Daliresp) is an oral medication used to decrease the frequency of exacerbations in severe COPD. This drug is a phosphodiesterase inhibitor, which is an antiinflammatory drug that suppresses the release of cytokines and other inflammatory mediators, and inhibits the production of reactive oxygen radicals. Respimat is an easy-to-use handheld device that provides a high deposition of drug to the lungs and low mouth and throat deposition. Respimat simplifies coordination between activation of the medication and inhalation without propellant, and it is independent of inspiratory flow. It also has a dose indicator. Combivent Respimat (ipratropium and albuterol) inhalation aerosol is now available O2 therapy is frequently used in the treatment of COPD and other problems associated with hypoxemia. Used clinically, it is considered a prescribed medication and the only one that has been proven to improve survival of COPD patients. Most methods of O2 administration are low-flow devices that deliver O2 in concentrations that vary with the person's respiratory pattern. The Venturi mask is a high-flow device that delivers fixed concentrations of O2 (e.g., 24%, 28% independent of the patient's respiratory pattern). A common device used for humidification when the patient has a cannula or a mask is a bubble-through humidifier. Another means of administering humidified O2 is via a nebulizer. It delivers particulate water mist (aerosols) with nearly 100% humidity. The humidity can be increased by heating the water, which increases the ability of the gas to hold moisture. Vapotherm Precision Flow can deliver high flows (up to 40 L/min) of warm humidified gas (air/oxygen) with precise percentages to the patient through a nasal cannula, and it is noninvasive. Because of combustion, a "No Smoking" sign should be prominently displayed on the patient's door. CO2 Narcosis - Normally, CO2 accumulation at the chemoreceptors is the major stimulant of the respiratory center. Over time some COPD patients with hypercapnia develop a tolerance for high CO2 levels (the respiratory center loses its sensitivity to the elevated CO2 levels). Theoretically, for these individuals a major "drive" to breathe is hypoxemia. Pulse oximetry and/or ABGs are used as a guide to determine what FIO2 level is sufficient and can be tolerated. Venturi masks may be used to have tighter regulation of the maximal FIO2 that is administered. With nasal cannulas, the oxygen flow rate is generally increased by 1 L per minute at a time. The goal is a pulse oxygen saturation (SpO2) of at least 90% or a PaO2 of at least 60 mmHg. Pulmonary O2 toxicity may result from prolonged exposure to a high level of O2 (PaO2). Absorption atelectasis - When high concentrations of O2 are given, nitrogen is washed out of the alveoli and replaced with O2. If airway obstruction occurs, the O2 is absorbed into the bloodstream, and the alveoli collapse. Infection - Infection can be a major hazard of O2 administration. Heated nebulizers that provide constant humidity support bacterial growth, with the most common organism being Pseudomonas aeruginosa. The improved prognosis results from preventing progression of the disease and subsequent cor pulmonale. Some patients believe they will become "addicted" to O2 and are very reluctant to use it. The nurse should tell them that it is not "addicting," and that it needs to be used because of the positive effects on the heart, lungs, and brain. Generally, the recommendation is that the patient should be reevaluated every 30 to 90 days during the first year of therapy and annually after that, as long as the patient remains stable. Short-term home O2 therapy (1 to 30 days) may be indicated for the patient in whom hypoxemia persists after discharge from the hospital. For example, the patient with underlying COPD who develops a serious respiratory infection may continue to have clearing of the infection after completion of antibiotic therapy and discharge from the hospital. (Each therapy is discussed in future slides.) The main types of breathing exercises are (1) pursed lip breathing (PLB) and (2) diaphragmatic breathing. However, the use of diaphragmatic breathing in patients with COPD may increase the work of breathing and dyspnea. A forced expiratory technique, huff coughing, is an effective technique that the patient can be easily taught. Chest physiotherapy (CPT) is used primarily for patients with excessive bronchial secretions who have difficulty clearing them (e.g., cystic fibrosis, bronchiectasis). Airway clearance devices include the Flutter, Acapella, and TheraPEP Therapy System. High-frequency chest wall oscillation technology uses an inflatable vest (e.g., The VestAirway system or the SmartVest) with hoses connected to a high-frequency pulse generator. (A description and photo are available at http://www.thevest.com/products.) Pursed-lip breathing (PLB) gives the patient more control over breathing, especially during exercise and periods of dyspnea (see Table 28-13). Patients should be taught to use "just enough" positive pressure with the pursed lips because excessive resistance may increase the work of breathing. Diaphragmatic (abdominal) breathing focuses on using the diaphragm instead of the accessory muscles of the chest to (1) achieve maximum inhalation and (2) slow the respiratory rate. However, the use of diaphragmatic breathing in patients with COPD may increase the work of breathing and dyspnea. Patients with moderate to severe COPD with marked hyperinflation may be poor candidates for diaphragmatic breathing. Airway clearance techniques (ACTs) loosen mucus and secretions so they can be cleared by coughing. ACTs include effective coughing, chest physiotherapy, airway clearance devices, and high-frequency chest ventilation. A forced expiratory technique, huff coughing, is an effective technique that you can easily teach the patient. Before coughing, ensure that the patient is breathing deeply from the diaphragm. Place the patient's hands on the lower, lateral chest wall and then ask the patient to breathe deeply through the nose. You should feel the patient's hands move outward, which represents a breath from the diaphragm. CPT consists of postural drainage, percussion, and vibration. CPT should be performed by an individual who has been properly trained. Contraindications for CPT include situations that involve head, neck, chest, or back instability and/or injury; anatomic deformity; severe spasticity; mental limitations; or in which the patient cannot tolerate the position for other reasons. Complications associated with improperly performed CPT include fractured ribs, bruising, hypoxemia, and discomfort to the patient. Percussion, vibration, and postural drainage assist in bringing secretions into larger, more central airways. The purpose of various positions in postural drainage is to drain each segment toward the larger airways. Effective coughing (huff coughing) is then necessary to help raise these secretions. In acute situations, postural drainage may be performed as frequently as every 4 hours. The procedure should be planned to occur and should be completed at least 1 hour before meals or 3 hours after meals. A thin towel should be placed over the area to be percussed, or the patient may choose to wear a T-shirt or hospital gown. Some positions for postural drainage (e.g., Trendelenburg) should not be performed on the patient with chest trauma, hemoptysis, heart disease, pulmonary embolus, or head injury, and in other situations where the patient's condition is not stable. Vibration is accomplished by tensing the hand and arm muscles repeatedly and pressing mildly with the flat of the hand on the affected area while the patient slowly exhales a deep breath. The Flutter has a mouthpiece, a high-density stainless steel ball, and a cone that holds the ball. When the patient exhales through the Flutter, the steel ball moves, which causes oscillations (vibrations) in the airways and loosens mucus. The patient must be upright, and the angle at which the Flutter is held is critical. It can be used in virtually any setting, as patients are free to sit, stand, or recline. The patient may also inhale through it, and nebulizers can be attached to the Acapella. TheraPEP has a mouthpiece attached to tubing connected to a small cylindric resistor and a pressure indicator. The pressure indicator provides visual feedback about the pressure that the patient needs to hold in an exhalation to receive the PEP. Weight loss is a predictor of a poor prognosis and increased frequency of COPD exacerbations. Malnutrition in COPD patients is multifactorial including increased inflammatory mediators, increased metabolic rate due to the ventilatory effort, and lack of appetite. Other factors that contribute to malnutrition in COPD include altered taste caused by chronic mouth breathing, excessive sputum, fatigue, anxiety, depression, increased energy needs, numerous infections, and side effects of polypharmacy. A diet high in calories and protein, moderate in carbohydrate, and moderate to high in fat is recommended and can be divided into five or six small meals a day. Underweight patients with emphysematous COPD may need 25 to 45 kcal/kg and 1.2 to 1.9 g of protein per kilogram to even maintain their weight. Assess the patient's dentition because broken or missing teeth or loose dentures make eating more difficult. Activity such as walking or getting out of bed during the day can stimulate the appetite and promote weight gain. Sensations of bloating and early satiety when eating can be attributed to swallowing air while eating, side effects of medication (especially corticosteroids and theophylline), and the abnormal position of the diaphragm relative to the stomach in association with hyperinflation of the lungs. Foods that require a great deal of chewing should be avoided or served in another manner (e.g., grated, pureed). Assess the patient's dentition because broken or missing teeth or loose dentures make eating more difficult. LVRS can also allow the diaphragm to return to its normal shape, allowing the patient to breathe more efficiently. Lung volume reduction surgery is being explored as a therapy that can be performed via a bronchoscope (BLVR). The valves let air out, but not in. This collapses a certain segment of the lung and has a similar result as LVRS. The bullae are usually resected via thoracoscope. Lung transplantation is discussed in Chapters 13 and 27.

COPD Exacerbations

Signaled by change in usual - Dyspnea - Cough - Sputum Exacerbations are signaled by an acute change in the patient's usual dyspnea, cough, and/or sputum (i.e., something different from the usual daily patterns). Classic signs of exacerbation include an increase in dyspnea, sputum volume, and/or sputum purulence. The severity is determined by the patient's medical history before the exacerbation, the presence of other diseases, current symptoms, ABGs, and other laboratory tests. Patients may also have nonspecific complaints of malaise, insomnia, fatigue, depression, confusion, decreased exercise tolerance, increased wheezing, or fever without other causes. 1. Associated with poorer outcomes 2. Primary causes - Bacterial and viral infections 3. Signs of severity - Use of accessory muscles - Central cyanosis Exacerbations of COPD are typical in the course of the disease with increasing frequency (average one to two a year) as the disease progresses. As the severity of COPD increases, exacerbations of COPD are associated with poorer outcomes. The primary causes of exacerbations are bacterial or viral infections. Signs of severity include use of accessory muscles, central cyanosis, development of edema in the lower extremities, unstable blood pressure, right-sided heart failure, and altered alertness. Treatment 1. Short-acting bronchodilators 2. Oral systemic corticosteroids 3. Antibiotics 4. Supplemental oxygen therapy Short-acting β2 - agonists with or without short-acting anticholinergics are preferred for those who are breathless. Drug administration via metered dose inhaler or nebulizer is equal in effect, although sicker patients often prefer the nebulizer. Antibiotic use remains somewhat controversial. However, the presence of green or purulent sputum (as opposed to white sputum) is one the best ways to determine if antibiotics are needed. Supplemental oxygen therapy may be used for inpatients and titrated by ABG measurement.

COPD Aging

Some degree of emphysema is common because of physiologic changes of aging lung tissue As people age, gradual loss of the elastic recoil of the lung occurs, along with stiffening of the chest wall, gas exchange alteration, and decrease in exercise tolerance. The lungs become more rounded and smaller. The number of functional alveoli decreases as peripheral airways lose supporting tissues. These changes are similar to those seen in the patient with emphysema. Clinically significant emphysema, however, usually is not caused by aging alone.