C.O.P.D.

Charles Williams RRT, AE-C

What is C.O.P.D.?
COPD is an acronym for Chronic Obstructive Pulmonary Disease. It is generally applied to patients who show persistent airway obstruction and decreased expiratory flow rates.

What is C.O.P.D.?
COPD is the 4th leading cause of death in the United States. Approximately 14-16 million people in the U.S. are currently diagnosed with COPD. COPD is the second leading cause of disability. Men are 7x more likely to be diagnosed with COPD than women.
Source: http://www.copd-international.com/library/statistics.htm

What is C.O.P.D.?
Physical Appearance of COPD patients:
Anxious Increased WOB/ use of accessory muscles Barrel-chested (result of air-trapping) Pursed-lip breathing Prolonged expiratory time Clubbing Cyanosis Diminished and/or adventitious breath sounds

What is C.O.P.D.?
There are two main types of COPD: Chronic Bronchitis Emphysema
*Some patients have characteristics of both

Other obstructive lung diseases: Asthma Bronchiectasis Cystic Fibrosis

What is C.O.P.D.?
Chronic Bronchitis: Chronic cough with excessive sputum production for 3 months per year for 2 or more consecutive years.

What is C.O.P.D.?
Chronic Bronchitis: The lining of the airways are constantly irritated and inflamed, becoming permanently thickened. Mucous secreting glands increase in size and number, producing excess mucous.

What is C.O.P.D.?

What is C.O.P.D.?
Chronic Bronchitis Causes: Cigarette smoking (leading cause) Air pollution Occupational exposure Chronic infections

What is C.O.P.D.?
Chronic Bronchitis Clinical manifestations:
Smokers cough Morning cough Chronic cough
Sputum production gradually increases until it is abnormally continuous. Is usually thick, grey, and mucoid until chronic infections develop. Then becomes mucopurulent.

What is C.O.P.D.?
Emphysema: Alveolar septal walls become damaged or destroyed, along with loss of elastic tissue.

What is C.O.P.D.?
Emphysema: Damaged alveoli lose their shape and become floppy. This leads to air-trapping, increased WOB, and impaired oxygenation/ventilation.

What is C.O.P.D.?

What is C.O.P.D.?
Emphysema Causes: Cigarette smoking (leading cause) Air pollution Occupational exposure Heredity (Alpha 1-antitrypsin deficiency)

What is C.O.P.D.?
Emphysema
Alpha 1-antitrypsin deficiency:
Genetic disorder Alpha 1-antitrypsin is produced in the liver, protects the lungs from the neutrophil elastase enzyme. Causes emphysematous changes to the lungs. (young age; no smoking history). Also characterized by liver disease and elevated liver enzymes.

What is C.O.P.D.?
Emphysema Clinical manifestations: Usually have a dry, non-productive cough. Patients sometimes appear malnourished (anorexic) secondary to loss of appetite.

COPD and Ventilatory Drive

Ventilatory drive is controlled by the peripheral and central chemoreceptors. Located in the aorta and carotid arteries, and also the medulla. Sensitive to oxygen concentration (O2), carbon dioxide (CO2), and pH of the blood and CSF. Under normal conditions, breathing is regulated by CO2 levels.

COPD and Ventilatory Drive

Because of the disease process, some COPD patients become CO2 retainers. They maintain continuously high levels of CO2. They become less sensitive to CO2, and more sensitive to O2. O2 then becomes the primary stimulus for breathing. If O2 if given in sufficient amounts or too much is given, breathing may be suppressed to the point of apnea. These patients require a small amount of hypoxia as their stimulus to breath. This is known as the hypoxic drive.

COPD and Ventilatory Drive

Key points: COPD patients that are on a hypoxic drive are rare. Not all COPD patients are CO2 retainers. Not all CO2 retainers are on a hypoxic drive.

Managing COPD Acute exacerbations Long-Term maintenance

Managing COPD
Acute Exacerbations: Treat comorbid conditions
(pneumonia, CHF)

Oxygen Therapy
(Titrated to maintain pO2 60 mm , SpO2 90%)

Medications
(bronchodilators, corticosteroids, antibiotics, etc.)

Ventilatory Support
BiPAP, mechanical ventilation

Managing COPD
Long-Term maintenence: Prevent progression of disease
(Smoking cessation, etc.)

Improve exercise tolerance Prevent and treat complications

(CHF, Cor Pulmonale)

Managing COPD
Nursing tips: Titrate oxygen to keep O2 sat 90% Encourage pursed-lip breathing for shortness of breath

Managing COPD
Pursed-lip breathing
Sit in a comfortable position and relax. Slowly take a deep breath in through your nose. Draw your lips together as if you were going to whistle and blow out through pursed lips slowly and evenly. Try to make the time blowing out longer than when you took a breath in. (inhale 2 sec/exhale 4 sec) Repeat this several times until your shortness of breath disappears.

Sources:
The Essentials of Respiratory Care; Kacmarek, Dimas, Mack Respiratory Care: Principles & Practice; Hess, MacIntyre National Heart, Lung, and Blood Institute Website:
(http://www.nhlbi.nih.gov/health/dci/Diseases/Copd/)